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Presented  by 
Dr.  M,  F.  Decker 


COLLEGE    OF    OSTEOPATHIC    PHYSICIANS     fc 


AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA 


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DISEASES 


OF  THE 


EECTUM   AND    ANUS 


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CHAELES  B.  KELSET,  M.D., 

SURGEON  TO  ST.   PATTL'S  INFIRMitRY  FOB   DISEASES  OF  THE  RECTUM  ;  CONSULTINO 

80EOEON  FOR  DISEASES  OF  THE  RECTUM  TO  THE   HARLEM    HOSPITAL  AND 

DISPENSARY  FOR  WOMEN  AND  CHILDREN     ETC.,    ETC. 


NEW   YORK 

WILLIAM    WOOD    <fe    COMPANY 

66  <&  58  Lafayette  Place 

1882 


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COPYHIOHT  BY 

WILLIAM    WOOD    &    COMPAlTr 
1882. 


STEAM  PRESS  OF 

H.  O.  A.  Industrial  School, 

187  &  189  E.  76th  St.,  New  York 


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PREFACE. 


Ix  preparing  the  following  pages  for  publication,  I  have  endeavored 
to  condense  into  convenient  form,  for  both  student  and  practitioner,  as 
great  an  amount  as  possible  of  practical  information  concerning  diseases 
of  the  rectum  and  anus. 

The  advances  which  have  been  made  during  the  past  few  years  in 
this  special  branch  of  surgery  have  been  very  great.  The  whole 
patholog}"  of  malignant  disease  has  been  rewritten ;  and  the  close 
relationship  of  the  so-called  benign  polypoid  growths  to  epithelial  can- 
cer has  been  worked  out  after  careful  study  with  the  microscope.  The 
operation  of  excision  of  cancerous  growths  in  the  lower  part  of  the  rec- 
tum has  again  become  a  legitimate  surgical  procedure,  and  what  is  bet- 
ter, its  range  of  applicability  has  been  definitely  determined.  The 
advances  in  abdominal  surgery,  for  which  the  present  century  will 
always  be  famous,  have  also  had  a  bearing  on  diseases  of  the  rectum, 
and  the  operation  of  excision  of  cancer  of  the  upper  part  of  the  rectum 
and  the  sigmoid  flexTire,  through  an  incision  made  in  the  abdominal 
wall,  has  brouglit  within  treatment  a  class  of  cases  formerly  beyond  the 
reach  of  art. 

New  methods  of  treatment  of  benign  stricture  have  been  devised 
as  a  substitute  for  colotomy.  New  methods  of  palliation  in  benign 
and  malignant  stricture  have  been  devised  as  substitutes  for  the  repul- 
sive operation  of  colotomy,  and  that  operation  bids  fair  in  the  imme- 
diate future  to  assume  deservedly  a  place  of  less  prominence  than  it 
has  occupied  in  the  past.     New  and  effectual  methods  of  curing  haem- 


IV  PREFACE. 

orrlioids  and  prolapse  mthout  cutting  operations  have  been  added  to 
the  surgeon's  resources. 

The  advances  have  been  due  to  the  efforts  of  no  one  man  or  nation. 
The  records  of  them  are  scattered  through  English,  Continental,  and 
American  periodical  literature,  and  many  of  them  are  practically  beyond 
the  reach  of  the  busy  practitioner. 

I  have  tried,  therefore,  as  far  as  possible  to  condense  what  was  pos- 
itively known  within  the  following  pages,  and  to  reduce  it  to  a  form 
suitable  for  ready  reference  by  student  and  practitioner,  giving  not 
only  the  results  which  have  been  reached  by  experiment  and  clinical 
experience,  and  wliich  may  be  relied  upon  as  the  basis  of  practice,  but 
in  many  questions  marking  out  by  foot-notes  and  references  the  way 
for  any  who  may  desire  to  go  over  for  himself  the  ground  which  I 
have  followed  with  no  little  difficulty. 

In  addition,  I  have  endeavored,  whenever  possible,  to  illustrate  the 
subject  under  consideration  by  the  reports  of  cases  either  from  my  own 
practice  or  that  of  others,  knowing  that  a  lesson  is  often  conveyed  to 
the  student  in  this  way  better  than  by  any  other. 

My  thanks  are  especially  due  to  the  librarians  of  the  Kew  York 
Hospital  for  their  unvarying  kindness  and  assistance,  which  has  ren- 
dered my  work  a  far  from  unpleasant  one. 

Chakles  B.  Kelsey. 
"The  Madison,"  No.  25  Madison  Ave., 
Corner  of  25th  Street, 
New  York,  September,  1882. 


CONTENTS. 


CHAPTER    I. 

PRACnCAL  POINTS  IX   ANATOMY  AND  PHYSIOLOOY. 

f 

Rectum. — Position  and  Measurements. — Curves.  —  Divisions. — Relations.— 
Arms. — Parts  in  Detail. — Peritoneum. — Relations  to  Three  Portions  of  the 
Rectum. — Distance  of  Peritoneal  Cul-de-Sac  from  Anus. — Muscular  Lay- 
er.— Arrangement  of  Fibres. — Submucous  Layer. — Mucous  Membrane. 
— Sustentator  Tunica?  Mucosae.  —  Columnae  Recti. — Glands  of  Mucous 
Membrane. — Muscles  of  the  Rectum  and  Anus. — External  Sphincter. — 
Internal  Sphincter. — Recto-Coccygeus. — Levator  Ani. — Transversus  Peri- 
nei, — Arteries.— Superior  Hemorrhoidal.  — Middle  Hsemorrhoidal. — In- 
ferior Hiemorrhoidal. — Veins. — Superior  Haemorrhoidal. — Middle  Heemor- 
rhoidal. — Inforior  Haemorrhoidal. — Minute  Anatomy  of  Veins. — General 
and  Visceral  Venous  Systems. — Nerves. — Cerebro-Spinal  and  Sympathe- 
tic Nerve  Supply. — Tonic  Contraction  of  Sphincter. — Explanation  of 
Wandering  Pains  in  Rectal  Disease. — Lymphatics.—  External  and  Internal 
Lymphatic  Vessels. — Physiology. — Aftatomy  of  the  Third  Sphincter.— 
Valves  of  Mucous  Membrane. — Plica  Transversalis  Recti  of  Kohlrausch. 
— Lack  of  Uniformity  in  Dififerent  Subjects. — Physiology  of  Defecation. 
— Explanation  of  Retention  of  Faeces  after  Destruction  of  the  Sphincter. 
— Conclusions  Resulting  from  Study  of  Third  Sphincter     .... 

CHAPTER    II. 

CONGENITAL  MALFORMATIONS  OF  THE  RECTUM   AND  ANUS. 

Se[»arate  Development  of  Rectum  and  Anus. — Narrowing  of  the  Anus  or  Rec- 
tum without  Complete  Occlusion. — Congenital  Stricture. — Closure  of  the 
Anus  by  a  Membranous  Diaphragm.  —Entire  Absenceof  the  Anus,  the  Rec- 
tum Ending  in  a  Blind  Pouch  at  a  Point  more  or  Less  Distant  from  the 
Perineum  — Ile(^tuiu  Same  as  in  Last  Variety  and  the  Anus  Normal. — 
Anus  Absent  and  Rectum  Oiiening  by  an  Abnormal  Anus  at  Some  Point 
in  the  Perineal  or  Sacral  Regions. — Ca.ses. — Anus  Absent  and  Rectum 
F-nding  in  the  Bladder,  Urethra,  or  Vagina. — Cases. — Rectum  and  Anus 
Normal,  but  Ureters,  Uterus,  or  Vagina  Empty  into  Rectum. — Total  Ab- 
sence of  Rectum. — Alwence  of  Large  Intestine. — Obliteration  from  Intra- 
uterine Disease. — Treatment. — Operation  Should  Always  be  Performe*! 
and  Without  Delay. — Attempt  Should  First  Ikj  Made  to  Establish  an  Anus 


VI  CONTENTS. 

PAGB 

in  the  Anal  Region. — Measurements  of  Pelvis  at  Birth. — Use  of  Trocar 
not  Justifiable. — Useful  Anus  Seldom  Obtained  by  Means  of  Incision 
Alone. — Objections  to  Cutting  Operation  Without  Plastic  Operation. — 
Proctoplasty. — If  Attempt  to  Establish  New  Anus  in  Anal  Region  Fail, 
Colotomy  at  Once  to  be  Performed.  —  Inguinal  Preferable  to  Lumbar 
Colotomy. — History  of  Colotomy.— Callisen. — Amussat. — Description  of 
Operation  of  Colotomy. — Dangers  of  Operation. — The  Inguinal  Opera- 
tion.— Description. — Attempts  at  Establishing  Anus  in  Anal  Region  after 
Colotomy  Generally  Unsuccessful. — Cases. — Closure  of  Artificial  Anus. — 
Operation  of  Dupuytren. — Modifications  of  Dupuytren's  Operation    .        .    30 


CHAPTER    III. 
< 

GENERAL  RULES  REGARDING  EXAMINATION,   DIAGNOSIS,   AND  OPERATION. 

Necessity  for  Physical  Examination. — Questions  which  may  lead  to  Diagno- 
sis.— How  to  make  Examination. — Table. — Lamp. —Instrument  Case. — 
Position  of  Patient. — Necessity  for  Enema  before  Examination. — What 
may  be  learned  by  simple  Inspection. — Rectal  Touch. — What  may  be 
discovered  by  it. — ^Bougies;  Varieties;  Author's  Bougies. — Rectal  Specula: 
Van  Buren's;  Fenestrated;  Bivalve;  Objections. — Colonoscope. —Stretch- 
ing the  Sphincter;  Proper  Method  of  Performing  the  Operation;  Resiilts. 
— Difficulties  of  Diagnosis  of  Disease  high  up  in  the  Rectum. — Manual 
Examination. — What  may  be  Learned  by  this  Method. — Preparation  of 
Patient  for  Operation. — Assistants. — Primary  AnsBsthesia. — Thermo-Cau- 
tery. — Hcemorrhage. — Rules  for  Controlling  Haemorrhage. — Cold. — Styj)- 
tics. — Packing  the  Rectum. — Treatment  after  Operation.— Dressings. — 
Necessity  for  Rest. — Retention  of  Urine. — Case  of  Fatal  Retention    .        .    48 


CHAPTER    IV. 

INFLAMMATION  OF  THE   RECTUM. 

Cases  of  Proctitis. — Varieties  :  Acute,  Chronic,  Primary,  Secondary,  Local- 
ized, General. — Symptoms  and  Course  of  each  Variety. — Causes  of  Proc- 
titis :  Direct  Propagation,  Foreign  Bodies,  Drastic  Cathartics,  Gout, 
Pederasty,  Gonorrhoea. — Treatment 66 


CHAPTER   V. 

ABSCESS  AND  FISTULA. 

Abscess  divided  into  Superficial  and  Deep. — Superficial  Abscesses. — Simple 
Furuncles;  Causes;  Characters;  Results;  Treatment. — Suppuration  of  Ex- 
ternal Haemorrhoid. — Suppuration  of  Internal  Hsemorrhoid. — Diffuse  In- 
flammation of  Subcutaneous  Tissue,  Causes;  Symptoms;  Treatment. — 
Form  of  Incision. — Deep  Abscesses. — Divided  into  Abscess  of  the  Ischio- 
Rectal  Fossa  and  of  the  Superior  Pelvi-Rectal  Space. — Cai  ses;  Symp- 
toms; Diagnosis. — Dangers  of  Deep  Abscess. — Formation  of  Deep  and 
Extensive  Fistulae. — Horse-shoe  Abscess. — Idiopathic  Gangrenous  Cel- 
lulitis.— Reasons  why  Abscesses  do  not  Heal  Spontaneously. — Prognosis. 
— Treatment. — Incisions  and  Subsequent  Treatment  of  Deep  Abscesses. — 


CONTENTS.  VU 


Incontinence  of  Faeces. — Relief  of  Incontinence  resulting  from  Operation. 
— Fistula.  —  Generally  due  to  Abscess.  —  Divided  into  Superficial  and 
Deep. — Complete  Fistula.  —  External  Fistula.  —  Internal  Fistula.  —  De- 
scription of  Superficial  Fistulae. — How  to  Detect  an  Internal  Opening. — 
Location  of  Internal  Opening. — Description  of  Track  of  Fistula. — Symp- 
toms of  Superficial  Fistula.  — Deep  Fistula. — Fistula  with  Numerous  Ex- 
ternal Ojjenings. — Blind  Internal  Fistula. — Ulceration  of  Rectum  Causing 
Internal  Fistula. — Treatment. — Spontaneous  Cure. — Advisability  of  Ope- 
ration.— Fistula  in  Relation  to  Phthisis. — Contra-indications  to  Opera- 
tion. —Treatment  by  Cauterization. — The  Ligature. — The  Elastic  Ligature. 
— Galvano-Cautery. — How  to  Pass  Ligature. — Incision. — Description  of 
Operation. — Author's  Knife  for  Fistula.  —  Division  of  Deep  Tracks. — 
Treatment  of  Track  running  up  the  Bowel. — Treatment  of  Blind  Exter- 
nal Variety;  of  Horse-shoe  Variety;  of  Fistula  with  Numerous  External 
Openings. — Dressing  after  Incision. — Packing  the  Incision. — Hajmorrhage 
in  Operation. — Treatment  of  Blind  Internal  Variety. — Incurable  Fistulse. 
— Treatment  of  Deep  and  Extensive  Tracks. — Fistula  with  Stricture         .    71 

CHAPTER   VL 

HiCMORRHOIDS. 

Definition. — Division  into  External  and  Internal. — Differences  between  the 
two  Varieties. — External  Haemorrhoids. — Pathology. — Inflamed  Haemor- 
rhoids.—  Treatment. — Means  of  Prevention. — Palliative  Treatment. — 
Excision. — Internal  Haemorrhoids. — Division  into  Capillary,  Arterial,  and 
Venous. — Description  of  Capillary  Variety,  of  Venous  Variety,  of  Arterial 
Variety. — Symptoms  of  Internal  Haemorrhoids. — Strangulation. — Diag- 
nosis.— Treatment  of  Internal  Haemorhoids. — Palliative  Treatment. — Con- 
stitutional and  Local  Means  of  Palliation. — Treatment  of  Strangulation. 
— Curative  Treatment. — Haemorrhoids  Associated  with  Uterine  Disease. — 
Symptomatic  Haemorrhoids.  —  Radical  Cure.  —  Caustics.  —  Dangers  of 
Nitric  Acid. — Vienna  Paste. — Treatment  by  Carbolic  Acid  Injections; 
Cases  and  Cures. — Advantages  of  this  Treatment. — Treatment  by  Liga- 
ture.— Description  of  Operation. — Operation  with  Clamp  and  Cautery      .     i)! 

CHAPTER    VI  L 

PROLAPSE. 

Four  Varieties. — First  Variety:  Prolapse  of  the  Mucous  Membrane  Alone. — 
Second  Variety:  Prolapse  of  all  the  Coats  of  the  Rectum. — Third  Variety: 
Prolapse  of  the  Upper  Part  of  the  Rectum  into  the  Lower,  or  Invagina- 
tion.— Fourtli  Variety:  Invagination  in  the  Continuity  of  the  Bowel. — 
Prolapse  of  the  Mucous  Membrane  alone. — Causes. — Symptoms. — Treat- 
ment: Palliative  and  Curative. — Prolapse  with  Haemorrhoids. — Treat- 
ment by  Injections. — Cauterization.— Description  of  Operation. — Smitli's 
Clamp. — Dupuytren's  Operation. — Prolapse  of  the  Second  Degret^. — Pa- 
thological Changes. — Presence  of  Peritoneum.— Strangulation. — Dangers 
in  Forcible  Re<iuction. — Fatal  Case  of  R«Hlu(;tion.  -Advisability  of  Reduc- 
ing Infiameil  or  Gangrenous  Prolapse. — Excision  of  Prolapse  after  the 
Formation  of  a  Slough. — Dangers  of  Oi>eration  of  Excision  in  Extensive 


Vlll  CJOKTENTS. 

PAQE 

Prolapse. — Operation  by  Elastic  Ligature. — Third  and  Fourth  Varieties. 
— Differences  between  Tliird  and  Fourth. — Degrees  of  Invagination. — 
Anatomical  Appearances.  —  Pathology.  —  Relative  Frequency.  —  Symp- 
toms.— ^Physical  Signs. — Acute  and  Chronic  Forms. — Diagnosis. — Dif- 
ferential Diagnosis  from  Volvulus;  from  Stricture;  from  Internal  Hernia; 
from  Obstruction  by  Pressure  from  without  the  Bowel;  from  Foreign 
Bodies;  from  Peritonitis  with  Perforation. — Treatment. — Replacement  by 
Manipulation;  by  Injections. — Treatment  by  Puncture. — Laparotomy. - 
Description  of  Operation 110 

CHAPTER    VII  L 

NON-MALIGNANT  GROWTHS  OF  THE  RECTUM  AND  ANUS. 

Polypus. — Definition. — Hypertrophy  of  Villi. — Characteristics. — Villous  Tu- 
mor.— Adenomatous  Polypus. — Fibrous  Polypus. — Structure;  Character- 
istics.— Symptoms  of  Polypus. — Diagnosis. — Diagnosis  from  Malignant 
Disease. — Treatment. — Vegetations.  —  Definition. — Description.  —  Micro- 
scopic Appearances. — Relation  to  Syphilis. — Symptoms  of  Vegetations. — 
Diagnosis. — Treatment. — Condylomata. — Distinction  between  Condylo- 
mata and  Vegetations. — Description. — Syphilitic  and  Non-syphilitic  Con- 
dylomata.— Benign  Fungus. — Gummata. — Rarity  and  Literatui'e. — Ano- 
rectal Syphiloma. — Definition  of  Fournier. — Fibromata. — Lipomata. — 
Characteristics. — Enchondromata. — Cysts. — Dermoid  Growths. — Charac- 
ters.— Pilo-Nidal  Sinus. — Hydatids. — Foetal  Inclusions. — Spina  Bifida. — 
Congenital  Cysts      ...-.., 135 

CHAPTER    IX. 

NON-MALIGNANT   ULCERATION. 

Varieties. — Simple  Ulcers. — Generally  due  to  Traumatism. — Various  Forms 
of  Injury  to  which  Rectum  is  Subject. — Sodomy. — Injury  of  Rectum  in 
Labor. — Ulcers  due  to  Surgical  Interference. — Fissure  or  Irritable  Ulcer. 
— Nothing  Distinctive  in  the  Ulcerative  Process. — Characteristics  of  Irri- 
table Ulcer. — Theories  concerning  this  Form  of  Ulcer. — Description. — 
Herpes. — Tubercular  Ulceration. — Distinction  between  True  Tubercular 
Ulcer  and  a  Simple  Ulcer  in  a  Tuberculous  Person. — Description  of  Each. 
— Scrofulous  Ulceration. — Esthiomene. — Rodent  Ulcer. — Dysentery. — A 
Cause  of  Stricture. — Venereal  Ulceration. — Gonorrhoea. — Chancroids. — 
Chancroidal  Stricture. — Discussion. — True  Chancre. — Secondary  and  Ter- 
tiary Syphilitic  Ulcerations. — Diagnosis  of  Syphilitic  Ulcers. — Ano-rectal 
Syphiloma  as  a  Cause  of  Ulceration. — Ulceration  Secondary  to  Stricture. 
— Gangrene. — Symptoms  of  Ulceration. — Gravity  of  the  Disease. — Diag- 
nosis.— Treatment. — General  and  Local  Measures. — Treatment  of  Fissure. 
— Fissure  Complicated  with  Polypus. — Treatment  by  Rest,  Fluid  Diet  and 
Incision  of  the  Sphincter. — Local  Applications 158 

CHAPTER    X. 

NON-MALIGNANT  STRICTURE  OF  THE  RECTUM. 

Stricture  due  to  Changes  in  the  Rectal  "Wall  and  to  Pressure  from  Without. — 
Spasmodic  Stricture. — General  Division  into  Venereal  and  Non-Venereal 


CONTKNT8.  IX 

PXGE 

Strictures  and  into  Fibrous  and  CicatriciaL — Frequence  of  Syphilis  in 
(>>nnection  with  Stricture. — Non- Venereal  Strictures. — Congenital,  Dys- 
enteric, Traumatic,  Varieties. — Stricture  from  Hj'pertrophy  of  Valves. 
— Pathological  Anatomy. — Changes  in  Rectal  Wall  above  and  below  the 
Stricture. — Changes  in  Parts  around  the  Stricture. — Symptoms. — Value 
of  Flattened  Passages  as  Symptom. — Signs  of  Obstruction. — Obstruction 
with  Stricture  of  Considerable  Calibre.  —  Diagnosis.  —  Dangers  to  be 
Avoided  in  Examination. — Difficulty  when  Disease  is  Situated  high  up 
in  the  Bowel. — Use  of  Bougie  for  Diagnosis. — ^Treatment. — Advisability 
of  Anti-Syphilitic  Medication.— Palliative  Treatment. — Medicinal  Treat- 
ment of  Threatened  Obstruction. — Surgical  Measures. — Dilatation,  Grad- 
ual or  Sudden  — Rules  for  Gradual  Dilatation. — Divulsion,  Dangers  of, 
and  Methods  of  Performing. — Treatment  by  Free  Division. — Description 
of  Operation. — Collection  of  Cases.— Results  of  this  Treatment. — Com- 
I)arison  with  Colotomy. — Cases  from  Author's  Practice. — Knife  for  Ope- 
ration.— Excision  of  Non-Malignant  Stricture. — Colotomy. — Restrictions 
to  the  Operation. — General  Considerations  Regarding  it. — ^Treatment  of 
Stricture  High  Up 181 


CHAPTER    XL 

CANCER. 

t]-neral  Ciiaracters  of  Malignant  as  Distinguished  from  Benign  Growths. — 
Malignant,  Semi-Malignant,  and  Benign  Adenoma. — Encephaloid.— Col- 
loid.— Melanotic  Cancer. — Osteoid  Cancer. — Age  at  which  Cancer  occurs. 
— Symptoms. — Diagnosis. — Treatment. — Excision:  History  and  Results  of 
Operation.— Conclusions  Regarding  Excision. — Modes  of  Performing  the 
Operation. —  Excision  of  Cancer  of  the  Sigmoid  Flexure. — Palliative 
Treatment .218 


CHAPTER    XII. 

IMPACTED  FAECES  AND  FOREIGN  BODIES. 

Impacted  Faeces. — Intestinal  Concretions.  Diagnosis  and  Treatment  of  Im- 
paction.— Foreign  Bodies  Swallowed.  —  Results  which  may  Follow  the 
Swallowing  of  a  Foreign  Body. — Ulceration  and  Abscess. — Foreign  Bodies 
introduced  per  Anum. — Cases. — Prognosis. — Treatment. — Dangers  of 
Attempts  at  Removal. — Laparotomy  for  Removal. — Cases  Successful       .  252 


CHAPTER    XIII. 

PRURITUS  ANL 

Pruritus  Generally  a  Symptom  of  some  other  Disease.— Description.— Causes. 
— Relations  of  Internal  Haemorrlioids,  Fistula,  Worms,  Parasites,  and 
Eczema  to  Pruritus. — Treatment  of  Eczema. — HerjH's  and  Erythema. — 
Constitutional  Conditions  causing  Pruritus.  Dependence  ujxm  Consti- 
pation.— Treatment  of  Constipation. — General  Treatment  of  Pruritus       .  269 


X  CONTENTS. 

CHAPTER    XIV. 

SPASM  OF  THE  SPHINCTER,   NEURALGIA,   WOUNDS,  RECTAL  ALIMENTATION. 

PAGE 

Spasm  without  other  Disease.  —  Cases. — Authorities. — Symptoms. — Treat- 
ment.— Neuralgia. — Cases.  -  Diagnosis.  — Treatment. — Wounds. — Com- 
plications.— Spontaneous  Rupture. — Treatment  of  "Wounds. — Alimenta- 
tion. —  Physiology  of  Absorption.  —  Nutritive  Enemata.  —  Nutritive 
Suppositories 277 


LIST  OF  ILLUSTRATIONS. 


PAOB 

FiauRB    1.  Antero-posterior  curve  of  tlie  rectum, 2 

"         2.  Section  of  normal  rect.al  wall, 8 

"      *  3.  Section  of  rectal  mucous  membrane, 9 

**          4.  Rectal  veins  seen  from  without .  14 

"         5.  Rectal  veins  seen  from  within, 15 

*'         6.  Nerves  of  the  anus, 18 

"         7.  Third  variety  of  congepital  malformation,       .        .        .        .      ' .  32 

"          8.  Fourth  variety  of  congenital  malformation 33 

"          9.  Fifth  variety  of  congenital  malformation, 34 

10.  Sixth  variety  of  congenital  malformation, 35 

11.  Condition  of  bowel  after  colotomy, 46 

12.  Idem, 46 

13.  Enterotome  of  Dupuytren  in  jiosition, 47 

14.  Examining  table,  closed, 50 

15.  Examining  table,  opened, 50 

"        16.  Lamp  for  rectal  examinations, 51 

*'        17.  Case  for  rectal  instruments, 52 

"        18.  Blunt-pointed  bougie, 55 

*'        19.  Sharp-pointed  bougie, 56 

"       20.  Bougie  a  boule, 56 

"        21.  Van  Buren's  rectal  speculum, 58 

22.  Fenestrated  rectal  speculum, .'>9 

*•      28.  Bivalve  rectal  speculum 59 

24.  Rectal  depressor, 59 

••       25.  Endoscope, 60 

"       26.  Thermo-cautery, 63 

27.  Varieties  of  fistula, 78 

*'       28.  Fistula  with  double  track, 79 

"        29.  Idem, 79 

"        80.  AUingham's  ligature  holder, 84 

31.  Helmuth's  ligature  holder, 84 

82.  Author's  fistula  knife, 86 

33.  Gorget 86 

34.  Spring  scissors, 87 

35.  Forceps  for  haemorrhoids, 107 

36.  Smith's  clamp, 109 

37.  First  variety  of  prolapse, Ill 

"        38.  Second  variety  of  prolapse, Ill 

"       39.  Third  variety  of  prolapse, 112 


Xll  LIST    OF    ILLUSTRATIONS- 

PAGE 

Figure  40.  Rectal  supporter, 115 

41.  Rectal  polypus, 13G 

42.  Villous  polypus, 137 

43.  Microscopic  section  of  villous  polypus, 137 

44.  Glandular  polypus,         .        .        .         .        .        .        .        .        .       138 

45.  Vertical  section  of  glandular  polypus, 139 

46.  Vegetations  around  anus, 142 

47.  Condylomata, 147 

48.  Stricture  of  the  rectum, 184 

49.  Rectal  dilator 200 

50.  Wales's  dilator, 201 

51.  Knife  for  proctotomy 205 

52.  Cancer  of  the  rectum — Malignant  adenoma  (Stimson)        .         .       219 


DISEASES  OF  THE  RECTUM  AND  ANUS 


CHAPTER    I. 

PRACTICAL   POINTS  IN   ANATOMY   AN"D   PHYSIOLOGY. 

Bectuin.^Position  and  Measurements. — Curves. — Divisions. — Relations. — Anus. 
— Parts  in  Detail.  — Peritoneum.  — Relations  to  Three  Portions  of  the  Rectum.  — 
Distance  of  Peritoneal  Cul-de-Sac  from  Anus. — Muscular  Layer. — Ar- 
rangement of  Fibres. — Submucous  Layer. — Mucous  Membrane. — Susten- 
tator  Tunicse  Mucosae. — ColumnaB  Recti. — Glands  of  Mucous  Membrane. — 
Muscles  of  the  Rectum  and  Anus. — External  Sphincter. — Internal  Sphincter. 
— Recto-Ckx;cygeus. — Levator  Ani. — Transversus  Perinei. — Arteries. — Supe- 
rior Haemorrhoidal. — Middle  Haemorrhoidal. — Inferior  Haemorrhoidal. — 
Veins. — Superior  Haemorrhoidal. — Middle  Haemorrhoidal. — Inferior  Hae- 
morrhoidal.— Minute  Anatomy  of  Veins. — General  and  Visceral  Venous  Sys- 
tems.— Nerves. — Cerebro-Spinal  and  Sympathetic  Nerve  Supply. — Tonic 
Contraction  of  Sphincter. — Explanation  of  Wandering  Pains  in  Rectal  Dis- 
ease.— Lymphatics.— Elxternal  and  Internal  Lymphatic  Vessels. — Physiology, 
— Anatomy  of  the  Third  Sphincter.— Valves  of  Mucous  Membrane. — Plica 
Transversalis  Recti  of  Kohlrausch. — Lack  of  Uniformity  in  DiflFerent  Subjects. 
— Physiology  of  Defecation. — Explanation  of  Retention  of  Faeces  after  De- 
struction of  the  Sphincter. — Conclusions  Resulting  from  Study  of  Third 
Sphincter. 

The  rectum  is  the  terminal  portion  of  the  large  intestine  extending 
from  the  sigmoid  flexure  to  the  anus.  In  its  natural  position  its  length 
varies  in  different  persons  from  six  to  eight  inches.  When  dissected  out 
of  the  body  and  straightened,  it  will  be  found  to  measure  about  two 
inches  more.  Its  position  in  the  true  pelvis  is  comparatively  fixed;  and 
its  fixity  renders  it  the  more  liable  to  those  displacements,  such  as  inva- 
gination and  prolapse,  which  are  due  to  straining  at  stool;  and  accounts 
also  for  the  fact  that,  when  denuded  by  the  destruction  of  the  surround- 
ing cellular  tissue,  it  remains  separated  from  the  walls  of  the  pelvis,  and 
cannot  come  in  contact  with  the  adjacent  soft  parts  and  thus  undergo 
healing. 

1 


2  DISEASES   OP   THE    KECTUM   AND    ANUS. 

The  upper  limit  of  the  rectum  is  difficult  to  determine  with  accuracy, 
except  from  the  fact  that  it  is  separated  from  the  sigmoid  flexure  by  a 
slight  constriction  which  becomes  more  apparent  when  attempts  are  made 
at  dilatation.  From  this  tipper  point  it  gradually  expands  into  a  pouch, 
the  ampulla,  and  then  again  suddenly  contracts  under  the  grasp  of  the 
muscles  which  close  its  lower  end. 

Curves. — The  curves  of  the  rectum  are  exceedingly  important  in  a 
practical  point  of  view.  There  are  two,  one  antero-posterior,  the  other 
lateral.  The  former  is  double.  From  above  downwards  it  follows  the 
curve  of  the  sacrum  and  coccyx,  being  concave  in  front,  and  convex  be- 
hind. When  it  reaches  a  point  opposite  the  tip  of  the  coccyx  it  suddenly 
reverses  its  direction,  turns  sharply  backwards,  and  ends  at  the  anus 
about  one  inch  in  front  of  the  tip  of  that  bone. 

By  this  backward  curve  of  its  lower  end,  which  is  represented  in  an 
exaggerated  form  in  Fig.  1,  it  is  separated  from  the  vagina  in  the  female. 


Fig.  1. — Exaggerated  antero-posterior  curve  of  rectum. 

and  from  the  urethra  in  the  male,  by  a  triangular  space  having  its  base 
at  the  perineum,  its  upper  wall  at  the  vagina  or  urethra,  and  its  lower  at 
the  upper  wall  of  the  rectum.  The  angle  of  junction  of  these  two  curves 
is  well  marked,  measuring  from  twenty  to  thirty  degrees;  and  the  curve 
is  not  without  influence  in  the  function  of  defecation,  since,  by  it,  an. 
obstruction  is  formed  to  the  downward  course  of  the  faeces. 

The  lateral  curve  is  generally  a  single  one  from  left  to  right,  starting 
at  the  left  sacro-iliac  synchondrosis  and  ending  at  the  median  line  at  a 
point  opposite  the  third  sacral  vertebra,  from  which  point  it  generally 
passes  straight  on  to  the  anus.    This  curve  may,  however,  pass  beyond  the 


PEACTICAL    POINTS    IN   ANATOMY    AND    PHYSIOLOGY.  3 

median  line  to  the  right  in  its  lower  portion,  and  again  return  to  the 
median  line  at  the  anus.  It  is  subject  to  many  variations,  and  the  upper 
portion  may  be  more  or  less  twisted  on  itself  like  the  sigmoid  flexure. 

The  sigmoid  flexure  may  occupy  an  unnatural  position,  and  the  rectum* 
instead  of  commencing  at  the  left  sacro-iliac  junction  and  curving  towards 
the  right,  may  commence  at  the  right  and  curve  toward  the  left.  In  one 
case,  reported  by  Cruveilhier,'  where  the  sigmoid  flexure  was  in  the 
natural  position,  the  rectum  passed  almost  transversely  to  the  right  side 
as  far  as  the  right  sacro-iliac  junction,  and  then  returned  again  very 
obliquely  in  the  left  side. 

Divisions. — For  convenience  the  rectum  is  usually  divided  into  three 
portions,  named  first,  second,  and  third,  from  below  upward.  The  first 
extends  from  the  anus  to  the  tip  of  the  prostate;  is  about  an  inch  and  a 
half  long;  is  firmly  closed  by  the  sphincters;  and  gives  attachment  to  a 
portion  of  the  levator  ani  muscle.  On  account  of  the  direction  of  this 
portion,  which  is  the  reverse  of  that  next  above,  the  finger  should  never 
be  passed  toward  the  sacrum,  or  even  directly  inward  in  making  an  ex- 
amination; but  rather  toward  the  pubes.  Bearing  this  simple  anatomi- 
cal point  in  mind  will  often  save  the  patient  much  unnecessary  suffering. 
The  second  portion  is  often  described  as  reaching  from  the  apex  of  the 
prostate  to  the  recto- vesical  fold  of  peritoneum;  but,  as  the  point  of  du- 
plicature  of  the  peritoneum  is  not  only  variable  in  different  individuals,  but 
at  different  times  in  the  same  individual,  it  is  better  to  adopt  a  fixed  bony 
point,  as  the  third  piece  of  the  sacrum;  in  which  case  the  middle  portion 
will  measure  about  three  inches  in  length.  This  portion,  it  will  be  remem- 
bered, is  convex  backward,  following  the  curve  of  the  sacrum.  The  third 
portion  extends  from  the  third  sacral  vertebra  to  the  left  sacro-iliac  syn- 
chondrosis; its  lower  part  is  partially,  and  its  upper,  completely,  sur- 
rounded by  peritoneum;  which,  in  the  upper  part,  forms  the  meso-rectum 
attaching  it  to  the  sacrum. 

Relations. — The  most  important  surgical  relations  of  the  rectum  are 
on  the  anterior  surfjvce.  The  first  portion  is  surrounded  laterally  and 
posteriorly  by  a  bed  of  connective  tissue,  rich  in  ^it  and  blood-vessels,  and 
may,  therefore,  be  incised  on  either  side,  or  backward,  with  comparative 
safety.  In  front,  however,  it  is  directly  in  relation  with  the  membranous 
urethra  in  the  male,  and  with  the  vagina  in  the  female;  though  at  the 
anus  it  is  separated  from  them  both  by  its  backward  and  downward 
course.  This  intimate  relationship  with  the  urethra  is  often  taken  ad- 
vantage of  in  catheterism,  when  by  passing  the  finger  into  the  rectum  the 
tip  of  the  instrument  may  easily  be  felt;  and  it  also  explains  why  in  all 
operations  on  the  urethra  or  vagina  the  rectum  should  first  be  emptied 
to  save  it  from  being  wounded. 

In  the  second  portion  also,  the  lateral  and  posterior  surfaces  have  no 

'Anat.  Path..  Amer.  Edition.  1844,  p.  377. 


4  DISEASES    OF   THE   KECTIJM    AND   ANUS. 

special  surgical  relations;  while  the  anterior  is  in  direct  contact  with  the 
prostate,  the  base  of  the  bladder,  the  seminal  vesicles,  and  sometimes,  at 
its  tipper  limit,  with  the  peritoneal  fold  of  Douglas.  This  portion  is 
closely  connected  with  the  bladder  in  the  male,  and  Avith  the  vagina  in 
the  female,  by  connective  and  muscular,  tissue;  and  the  two  cavities  may 
easily  be  made  to  communicate  by  any  morbid  process  or  by  a  surgical  pro- 
cedure. It  was  at  this  point  that  the  trocar  was  plunged  from  the  rectum 
into  the  bladder  in  the  old  operation  of  puncturing  the  bladder  through 
the  rectum;  and  Hyrtl'  speaks  of  a  man  who  was  only  able  to  pass  his  water 
after  first  introducing  his  finger  into  the  rectum  and  raising  a  calculus 
out  of  the  trigone  of  the  bladder.  A  somewhat  analogous  case  is  reported 
in  which  a  long  slender  calculus  perforated  the  bladder  and  projected 
into  the  rectum,  from  which  it  was  easily  removed."  The  prostate,  when 
large,  may  project  over  the  sides  of  the  rectum,  or  the  latter  may  receive 
the  prostate  in  a  kind  of  gi'oove  on  its  upper  surface. 

The  third,  or  upper  portion,  unlike  the  other  two,  has  important 
surgical  relations  on  every  side.  Posteriorly  it  is  in  whole  or  part 
covered  with  peritoneum;  and  is  separated  from  the  sacrum  by  the  pyri- 
formis  muscle,  the  sacral  plexus  of  nerves,  and  the  branches  of  the  in- 
ternal iliac  artery.  On  its  sides  it  is  in  contact  with  the  adjacent  convo- 
lutions of  small  intestine,  and  lower  down,  with  the  levator  ani  muscle 
and  the  connective  tissue  of  the  ischio-rectal  fossa.  In  the  male  it  is  in 
relation,  in  front,  with  the  posterior  surface  of  the  bladder,  from  which 
it  is  separated  by  coils  of  small  intestine.  In  cases  of  retention  either  of 
urine  or  fseces  the  two  may  be  brought  into  actual  contact.  In  the 
iemale,  it  is  in  relation,  anteriorly,  with  the  broad  ligament,  the  left 
ovary  and  Fallopian  tube,  the  uterus  and  vagina.  When  the  rectum  and 
uterus  are  empty,  the  coils  of  small  intestine  pass  down  between  them  to 
the  bottom  of  the  fold  of  Douglas,  and  they  may  even  escape  through 
the  posterior  wall  of  the  vagina  in  case  of  injury. 

From  these  relations  it  is  apparent  that  enlargements  and  malposi- 
tions of  the  uterus  may  act  directly  upon  the  rectum.  The  vessels  may 
be  so  obstructed  as  to  cause  hemorrhoidal  troubles,  or  interfere  with 
operations  for  their  relief.  The  rectum  may  be  entirely  occluded  by  the 
pressure  of  a  uterine  tumor;  and  a  hasty  examination  of  the  rectum  may 
lead  to  the  diagnosis  of  a  cancerous  tumor  when  in  reality  the  normal 
uterus  alone  is  felt.  The  advantage  of  a  rectal  examination  in  all  doubtful 
cases  of  pelvic  disease  is  also  manifest. 

Tlie  Anus. — The  rectum  terminates  below  in  the  anus  which  is  tightly 
closed  by  the  external  sphincter  muscle.  The  skin  around  its  border  is 
thin  and  pigmented,  covered  with  fine  hair  in  the  male,  and  contains  a 
great  number  of  sebaceous  follicles  and  muciparous  glands.     The  skin 

^Topog.  Anat.,  ii.,  p.  103. 

•G<xx5h:  Chirurg.  Works,  London,  1792,  vol.  iii.,  p.  216. 


PBACnOAL    POENT8    IN    ANATOMY    AND   PHYSIOLOGY.  5 

passes  deeply  into  the  anal  orifice,  and  its  point  of  junction  with  the 
mucous  membrane  is  in  some  persons  indicated  by  an  indistinct  white 
line. '  This  white  line  of  junction  also  corresponds  to  the  division  between 
the  external  and  internal  sphincter  muscles;  and  also  to  the  point  at 
which  many  of  the  terminal  filaments  of  the  internal  pudic  nerve  per- 
forate the  gut.  Both  skin  and  mucous  membrane  at  the  anus  are  re- 
markable for  the  development  of  erectile  tissue;  the  arteries  coming 
from  the  inferior  haemorrhoidal,  and  the  veins  being  very  numerous, 
winding,  and  twisted.  The  presence  of  this  erectile  tissue  accounts  for 
the  habit  of  pederasty  which  will  occasionally  be  referred  to  as  a  cause 
of  rectal  disease.  It  is  a  habit  to  which  few  are  addicted  in  this  country, 
but  which  is  not  uncommon  in  some  other  parts  of  the  world.  In 
America  it  is  chiefly  seen  amongst  the  negro  race  and  on  shipboard 
amongst  sailors  who  are  on  a  long  voyage.  Among  the  latter  it  was  a 
vice  whose  existence  was  well  known  and  which  was  occasionally  punished 
by  the  officers  during  the  late  war.  The  nerves  are  derived  both  from 
the  cerebro-spinal  and  sympathetic  systems,  as  will  be  shown  later. 

After  these  general  considerations  of  the  position  and  relations  of 
the  rectum  as  a  whole,  the  individual  parts  may  be  taken  up  more  in 
detail.  The  rectal  wall  is  composed,  as  are  the  other  parts  of  the  intes- 
tine, of  four  layers:  an  external  or  peritoneal;  a  muscular,  divided  into 
longitudinal  and  circular;  a  sub-mucous  connective  tissue  layer;  and 
most  internally,  the  mucous  membrane.  The  total  thickness  of  these 
coats  collectively  varies  greatly  in  different  subjects,  the  variation  being 
chiefly  in  the  muscular  coat,  the  others  remaining  pretty  constantly  of 
the  same  thickness. 

Peritoneum. — The  upper  portion  of  the  rectum  is  entirely  surrounded 
by  peritoneum,  and  has,  beside,  a  fold  of  attachment  to  the  anterior  sur- 
face of  the  sacrum,  known  as  the  meso-rectum.  The  meso-rectum  is 
about  four  inches  long,  blends  with  the  meso-colon  above,  and  extends 
down  as  low  as  the  third  or  fourth  sacral  vertebra,  from  which  point  its 
two  layers  are  reflected  over  the  sides  and  anterior  surface  of  the  rectum 
on  to  the  posterior  wall  of  the  uterus  and  upper  limit  of  the  vagina  in 
the  female;  and  on  to  the  bladder  in  the  male,  forming  the  cul-de-sac  of 
Douglas.  The  meso-rectum  may  be  so  short  as  to  disappear  when  the 
rectum  is  distended,  or  it  may  be  entirely  absent;  in  which  case  the  peri- 
toneum pjisses  directly  from  the  sides  of  the  rectum  to  the  sacrum.  Be- 
tween its  two  layers  may  be  found  some  loose  connective  tissue,  the 
haemorrhoidal  vessels  and  nerves,  and  the  lymphatics. 

In  passing  from  the  limit  of  the  meso-rectum  behind,  to  form  the 
cul-de-sac  in  front,  the  peritoneum  covers  more  or  less  of  the  lateral  and 
anterior  surfaces  of  the  middle  portion  of  the  rectum.     As  before  men- 

'  Hilton:  Rest  and  Pain.  Wood's  Library  of  Standard  Medical  Authors,  p. 
166. 


6  DISEASES   OF   THE    RECTUM    AND    ANUS. 

tioned,  the  point  at  which  the  peritoneum  leaves  the  anterior  surface  a 
the  middle  portion  of  the  rectum  to  be  reflected  upon  the  posterior  sur- 
face of  the  bladder  in  the  male,  or  of  the  vagina  or  uterus  in  the  female, 
varies  in  different  subjects,  and  at  different  times  in  the  same  subject; 
and  hence  the  differences  in  its  distance  from  the  anus  as  given  in  differ- 
ent works  on  anatomy.  In  new-born  children  the  bottom  of  the  cul-de- 
sac  touches  the  upper  edge  of  the  prostate  and  approaches  to  within 
about  an  inch  of  the  anus.  At  five  years  it  rises  in  the  pelvis  with  the 
development  of  the  seminal  vesicles  and  internal  organs  of  generation; 
and  in  old  people  with  enlargeihent  of  the  prostate,  it  is  carried  still 
higher.  In  women  it  generally  extends  to  the  uj)per  border  of  the  poste- 
rior vaginal  wall;  so  that  the  latter  is  separated  from  the  rectum  by  peri- 
toneum for  about  one-third  of  an  inch.  By  every  expansion  of  the  blad- 
der or  rectum  as  well  as  by  tumors  of  the  pelvis  the  fold  is  carried  further 
away  from  the  anus,  as  may  easily  be  demonstrated  on  the  cadaver  by 
forcible  injections  of  the  bl&dder. 

The  average  distance  from  the  anus  of  the  point  at  which  the  serous 
coat  leaves  the  anterior  wall  of  the  rectum  is,  therefore,  very  difficult  to 
determine;  and  yet  it  is  of  the  greatest  importance  in  all  surgical  opera- 
tions on  the  part;  since  the  fact  of  opening  or  not  opening  the  peritoneal 
cavity  may  make  all  the  difference  between  life  and  death  in  the  result  of 
an  operation.  Dupuytren  gives  the  distance  as  seventy  mm.,  and  less  when 
the  organs  are  empty;  Lisfranc  gives  six  inches  in  the  female,  and  four 
in  the  male,  but  does  not  state  in  what  condition  of  the  organs  the  mea- 
surements are  taken;  Sappey,  Velpeau,  and  Legendre  give  five  and  a  half 
cm.  when  the  bladder  is  empty  and  eight  when  distended;  Quain  says  four 
inches;  Allingham  from  two  to  five  or  more.  Cripps,'  acting  on  the  idea 
that  the  fold  is  not  easily  displaced  downward  by  traction  on  the  rectum, 
has  experimented  by  filling  the  peritoneal  cavity  with  plaster,  and  then 
thrusting  a  needle  through  the  skin  of  the  perineum  till  its  point  struck 
the  plaster.  In  this  way  he  has  obtained  an  average  measurement  of  two 
and  a  half  inches  when  the  bladder  and  rectum  are  both  empty,  and  an 
additional  inch  when  distended." 

Musculai'  Coat. — In  the  fact  that  the  muscular  coat  is  arranged  in 
two  layers,  an  external  longitudinal  and  an  internal  circular,  the  rectum 
resembles  the  other  portions  of  the  alimentary  canal;  but  in  the  further 
arrangement  of  its  fibres  it  resembles  the  oesophagus  more  closely  than 
the  intermediate  portions.     The  fibres  ai'e  spread  out  into  two  uniform 

'  Cancer  of  the  Rectum.     London,  1880,  p.  129. 

*  The  following  authors  give  the  following  measurements:  Malgaigne,  male, 
6-8  cm.;  females,  4-6  cm.  Luschka,  5.5-8  cm.  Hyrtl,  8  cm,  Lisfranc  and 
Sanson,  11  cm.  Richet,  males,  10.8  cm.;  females,  16.2  cm.  Blaudin,  males,  8.1 
cm.;  females,  4.1  cm.  Ferguson,  males,  10.5  cm.;  females,  15.4  cm.  Esmarch: 
Die  Krankheiten  des  Mastdarms  und  des  Afters.  Pitha  u.  Billroth  :Chirurgie, 
p.  7. 


PEACnCAL   POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  7 

layers,  and  are  not  arranged  in  bands  crossing  each  other  in  a  basket  net- 
work and  leaving  sacculi  between  the  meshes. 

The  longitudinal  fibres  are  the  direct  continuation  of  the  three  longi- 
tudinal bands  of  the  large  intestine.  Upon  reaching  the  rectum,  these 
blend  into  one  continuous  sheath  which,  however,  is  somewhat  heavier 
on  the  anterior  surface  of  the  bowel  than  on  any  other.  At  the  point  of 
contact  of  the  rectum  with  the  bladder  and  prostate  these  fibres  are  in 
part  reflected  with  the  peritoneum  on  to  the  posterior  wall  of  the  latter 
and  thus  form  a  firm  band  of  union  between  the  two  organs,  as  has  been 
particularly  described  by  Dr.  Garson.*  They  have  been  named  by  him 
the  recto-vesical  fibres. 

The  ending  of  the  longitudinal  fibres  is  worthy  of  note.  According 
to  Horner,'  when  they  reach  the  lower  margin  of  the  internal  sphincter 
a  j)art  of  them  turn  upwards  between  it  and  the  external  sphincter  and 
ascend  for  an  inch  or  two  in  contact  with  the  mucous  coat  into  which 
tlioy  are  finally  inserted;  having,  therefore,  an  obvious  influence  in  caus- 
ing protrusion  of  the  mucous  membrane.  In  the  lower  fourth  of  their 
extent  these  fibres  become  weaker  and  less  distinct,  and  some  of  them 
finally  blend  into  elastic  tendinous  tissue  which  passes  between  the  bun- 
dles of  the  external  sphincter,  and  is  inserted  into  the  subcutaneous  con- 
nective tissue  of  the  anus.  Others  are  inserted  posteriorly  by  means  of 
an  elastic  tendon  about  an  inch  long  into  the  anterior  sacro-coccygeal 
ligament — an  arrangement  pointed  out  by  Luschka'  as  analogous  to  what 
is  found  in  most  mammalia,  in  whom  a  considerable  number  of  the  lon- 
gitudinal fibres  are  inserted  into  the  base  of  the  coccyx,  giving  a  fixed 
point  for  the  rectum  in  defecation. 

The  circular  layer  is  reinforced  at  certain  points;  notably  at  the  in- 
ternal sphincter  which  is  merely  a  collection  of  these  fibres,  and  at  a 
point  higher  up  where  they  are  again  gathered  into  a  bundle  either  partly 
or  completely  surrounding  the  bowel,  known  as  the  third  sphincter. 
This  muscle  will  be  described  more  fully  later. 

Submucous  Coat. — The  submucous  tissue  forming  the  bed  upon 
which  the  mucous  membrane  rests  is  suflBciently  lax  to  permit  of  consid- 
erable sliding  of  the  mucous  membrane  on  the  muscular  coat.  In  it  the 
blood-vessels  ramify,  and  from  it  perpendicular  processes  are  given  off 
which  perforate  both  the  internal  and  external  muscular  layers  and  are 
fi'ially  lost  in  the  sheaths  of  the  muscular  fibres,  or  go  entirely  through 
the  muscular  layer  and  blend  with  the  fibrous  stroma  of  the  surrounding 


'  The  Arrangement  and  Distribution  of  the  Muscular  Fibres  of  the  Rectum. 
Paper  read  before  the  Brit.  Med.  Ass.  Reported  in  Brit.  Med.  Jour.,  Sept.  6th, 
1879. 

*  A  Treatise  on  Special  and  General  Anatomy.  Vol.  ii.,p.  40,  Philadelphia, 
1826. 

*  Anat.  dea  Menschen.    Vol.  ii.,  Part  2,  p.  208. 


8  DISEASES    OF   THE   RECTUM    AND    ANTJ8. 

fatty  tissue.  These  processes  from  the  submucous  tissue,  together  with 
the  lymph  and  blood-vessels,  serve  to  bind  the  various  layers  of  the  rectal 
wall  together. '    See  Fig.  2. 

Mucous  Membrane. — The  mucous  membrane  of  the  rectum  corresponds 
in  its  general  characters  with  that  of  the  other  parts  of  the  bowel,  being 
modified,  however,  in  certain  particulars  to  suit  its  location  and  func- 
tion. Its  thickness  is  about  three-quarters  of  a  mm. ;  it  is  redder  and  more 
vascular  than  that  of  other  parts  of  the  large  intestine;  it  glides  freely  on 
the  tissue  beneath;  and  is  so  ample  as  to  be  gathered  into  folds  at  various 
points  which  are  of  considerable  surgical  and  anatomical  interest.  At 
its  point  of  union  with  the  skin  of  the  anus  it  is  gathered  into  vertical 
folds  which  diminish  when  the  bowel  is  distended,  but  do  not  entirely 
disappear,  and  hence  are  not  due  solely  to  the  contraction  of  the  sphinc- 
ter. These  vertical  folds  have  received  the  name  of  columnm  recti,  or 
columns  of  Morgagni;  and  Treitz  states  that  they  contain  bands  of  mus- 


Fig.  2.— Section  of  normal  rectal  wall  (Cripps). 

cular  fibres  running  longitudinally  and  terminating  above  and  below  in. 
elastic  tissue.  Kohlrausch"  also  describes  a  thin  layer  of  longitudinal 
muscular  fibres  under  the  mucous  membrane  at  this  point  and  has  named 
it  the  sustentator  tuniccB  mucosce;  but  most  anartomists,  with  Henle,  have 
failed  to  find  anything  more  than  the  stratum  of  muscular  tissue  common 
to  the  whole  mucous  coat,  and  known  as  the  muscularis  mucosce. 

Between  the  lower  ends  of  the  columnm  recti  little  arches  are  stretched 
from  one  to  the  other,  forming  pouches  of  skin  and  mucous  mem- 
brane. These  are  more  developed  in  old  people,  and  may  retain  small 
pieces  of  hardened  faeces  or  foreign  bodies  in  their  cavities,  and  thus  give 
rise  to  suppuration  and  abscess. 

The  mucous  membrane  may  for  the  purpose  of  study  be  divided  into 
three  separate  layers,  the  muscular,  glandular,  and  epithelial.     Fig.  3. 

'  Cripps,  op.  cit.,  p.  38. 

*  Anat.  u.  Physiol,  der  Beckenorgane,  Leipzig,  1854.  Beyer  also  says  they  are 
strengthened  by  muscular  fibres.    Traite  d'Anat,,  T.  iv.     Paris,  1815. 


PRACTICAL    POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  9 

The  muscular  layer  {muscular is  mucoscs,  sustentator  tunica  mucoscB) 
is  a  layer  of  unstriped  muscular  tissue  about  0.02  mm.  thick,  which  is 
everywhere  found  in  the  deepest  layer  of  the  mucous  membrane,  extend- 
ing from  the  oesophagus  to  the  rectum,  but  is  more  strongly  developed  in 
the  region  of  the  anus  where  it  serves  to  hold  the  membrane  in  place  and 
prevent  prolapse.  It  consists  of  bundles  running  in  some  parts  both  lon- 
gitudinally and  circularly,  and  in  others  in  one  direction  only;  and  which 
send  prolongations  up  between  the  glands  to  the  villi. 

The  glandular  layer  is  about  0.07  mm.  in  thickness.  It  consists  of  a 
layer  of  Lieberkuhn's  follicles  with  an  occasional  solitary  closed  follicle 
below  tliem,  the  situation  of  which  is  marked  by  a  slight  depression  in 
the  mucous  membrane,  and  an  absence  of  the  tubular  follicles  at  that 
point.  The  follicles  are  tubular  depressions  arranged  with  great  regu- 
larity and  set  so  closely  together  that  the  width  of  the  intervening  tissue 


Fio.  3.— Section  of  the  rectal  mucous  membrane  (Esmarch).  1.  Follicles  of  Lieberkuhn.  8. 
Muscular  layer  of  mucous  membrane.  3.  Submucous  connective  tissue  and  Tessels ;  with  a  soli- 
tary closed  follicle,  over  which  the  tubular  follicles  are  wanting:. 

is,  on  the  average,  about  one-sixth  the  diameter  of  the  follicle.  The 
length  of  the  tubes  is  four  or  five  times  their  diameter,  the  respective 
measurements  being:  length,  0.35  mm.;  diameter,  0.08  mm.  These 
tubular  depressions  or  follicles  are  lined  with  epithelial  cells  arranged 
with  their  bases  resting  on  tlie  connective  tissue  and  their  apices  free  in 
tiie  cavity  of  the  follicle;  and  the  cells  of  one  follicle  are  directly  contin- 
uous with  those  of  the  next  hanging  freely  into  the  lumen  of  the  bowel 
as  they  pass  over  from  one  depression  into  the  next.  The  appearance  of 
the  cells  is  analogous  to  that  of  a  bee's  honeycomb,  the  intervening  wall 
being  common  to  two  cells.  The  intertubular  tissue  consists  of  a  fine 
trabecular  network,  the  meshes  of  which  are  very  long  in  the  vertical 
direction  running  parallel  to  the  follicle  (Cripps). 

The  follicles  of  Lieberkulin  arc  simply  inverted  villi  and  answer  the 
same  purpose  of  absorption.  There  are  good  reasons  for  the  substitution 
of  follicles  for  villi  in  this  part  of  the  canal,  the  former  being  less  subject 


10  DISEASES   OF   THE   KECTITM    AND    ANTJS. 

to  injury  from  hardened  fseces,  and  the  fact  of  such  substitution  gathers 
great  weight  from  the  fact  that  in  certain  cases  where  an  artificial  anus 
has  been  established,  the  whole  bowel  below  that  point  has  been  found  in 
after-years  covered  with  a  growth  of  villi. ' 

Muscles  of  the  Rectum  and  Anus. — The  muscles  which  may  properly 
be  included  in  a  description  of  the  rectum  and  anus  are  the  external  and 
internal  sphincters,  the  levator  ani,  ischio-coccygeus,  retractor  recti  or 
recto-coccygeus,  and  the  transversus  perinei. 

External  Sphincter. — The  external  sphincter  muscle  is  a  thin  layer  of 
Toluntary  fibres,  about  half  an  inch  broad  on  each  side  of  the  anus,  sur- 
rounding it  in  the  form  of  an  ellipse,  and  having  a  narrow  pointed 
insertion  anteriorly  and  posteriorly.  It  is  situated  immediately  beneath 
the  skin,  and  extends  about  two  centimetres  up  the  bowel  where  its 
upper  limit  may  sometimes  be  seen  by  the  white  line  already  mentioned. 
It  is  divided  into  a  superficial  and  deep  portion.  The  superficial  is 
inserted  both  in  front  and  behind  into  the  subcutaneous  cellular  tissue. 
Tlie  deeper  and  thicker  portion  is  inserted  posteriorly  by  a  narrow  fiat 
tendon  into  the  posterior  surface  of  the  fourth  coccygeal  vertebra.  Be- 
tween the  tendon  and  the  bone  ia  a  bursa  about  the  size  of  a  pea — bursa 
mucosa  coccygea  of  Luschka.  Anteriorly  it  is  inserted  into  the  central 
tendon  of  the  perineum  in  common  with  the  transversus  perinei  and 
bulbo-cavernosus,  and  in  women  with  the  sphincter  vaginae.  The  action 
of  the  muscle  is  to  close  the  anus  and,  under  the  control  of  the  will,  to 
antagonize  the  proper  dilators  of  the  anus,  the  levator  ani  and  ischio- 
coccygeus,  as  well  as  the  peristaltic  action  of  the  bowel  and  the  contrac- 
tion of  the  diaphragm.  The  superficial  band  of  fibres  acts  only  in 
puckering  the  skin.  The  nerve-supply  comes  from  the  hasmorrhoidal 
branch  of  the  internal  pudic,  and  the  haemorrhoidal  branch  of  the  fourth 
sacral  nerve. 

Internal  Sphincter. — The  internal  sphincter  is  situated  immediately 
above  and  partly  within  the  deeper  portion  of  the  external  sphincter; 
being  separated  from  it  by  a  layer  of  fatty  connective  tissue.  Its  thick- 
ness is  about  two  lines;  its  vertical  measurement  from  half  an  inch  to  an 
inch;  and  it  is  a  direct  continuation  of  the  involuntary  circular  fibres  of 
the  bowel,  growing  thicker  and  stronger  as  it  approaches  the  anus.  It 
also  is  supplied  by  the  haemorrhoidal  branch  of  the  internal  pudic. 

Recto-coccygeus  (Retractor  recti,  Trietz;'  Tensor  Fasciae  Pelvis,  Kohl- 
rausch). — This  muscle  consists  of  two  flat  lateral  bands  of  unstriped 
fibres,  each  of  which  is  about  four  mm.  broad,  which  diverge  at  an  acute 
angle  from  the  anterior  coccygeal  ligament  at  the  tip  of  the  coccyx,  and 
passing  forward  and  downward,  embrace  the  lower  end  of  the  rectum  on 

'  Specimen  No.  1,288,  Museum  of  College  of  Surgeons  (Cripps). 
•^  Yierteljahrsschrift  f.   praktische   Heilkunde.      Prag,    1863,   Bd.   i.,   S.    124. 
Henle.  Abbildung  2,  183. 


I 


PKACnCAL    POINTS    I.V    ANATOMY    AND    PHYSIOLOGY.  11 

each  side  like  a  fork.  It  is  located  directly  under  that  portion  of  the 
levator  ani  which  forms  the  floor  of  the  pelvis  between  the  tip  of  the 
coccyx  and  the  anus;  and  blends  partly  Avith  the  longitudinal  muscular 
fibres  of  the  rectum,  and  partly  with  the  pelvic  fascia  surrounding  its 
end.  Its  function  is  to  hold  the  end  of  the  rectum  against  the  coccyx 
and  to  give  it  a  fixed  point  in  defecation. 

Levator  Am. — The  levator  ani  and  ischio-coccygeus  muscles  form  a 
true  diaphragm  to  the  pelvis  by  giving  an  uninterrupted  muscular  and 
tendinous  plane  from  the  lower  border  of  the  pyriformis,  behind,  to  the 
arch  of  the  pubes  in  front.  That  part  which  is  named  ischio-coccygeus 
is  usually  described  as  a  separate  muscle,  though  in  no  way  differing  in 
function  from  the  larger  portion,  and  only  distinguishable  from  it  by  its 
more  tendinous  structure.  It  is  situated  just  in  front  of  the  sacro-sciatic 
ligaments,  and  arises  by  aponeurotic  fibres  from  the  sides  and  tip  of  the 
spine  of  the  ischium,  from  the  anterior  surface  of  the  lesser  sacro-sciatic 
ligament,  and  often  from  the  posterior  part  of  the  pelvic  fascia.  It  is  in- 
serted, also  by  aponeurotic  fibres,  into  the  border  of  the  coccyx  and  lower 
part  of  the  border  of  the  sacrum.  Owing  to  its  tendinous  origin  and  in- 
sertion, the  greater  part  of  the  muscle  is  composed  of  aponeurotic  fibres. 
It  is  in  relation  superiorly,  by  its  concave  surface,  with  the  rectum; 
inferiorly,  by  its  convex  surface,  with  the  sacro-sciatic  ligaments  and  the 
gluteus  maximus;  posteriorly,  its  border  is  in  contact  with  the  lower 
border  of  the  pyriformis;  and  anteriorly,  it  is  directly  continuous  with 
the  fibres  of  the  levator  ani.  Its  action  is  to  draw  the  coccyx  to  its  own 
side,  or,  when  both  muscles  act  together,  to  fix  that  bone  and  prevent  its 
being  thrown  backward  in  defecation.  It  probably  has  no  such  action  as 
would  justify  the  name  of  levator  coccygis,  given  it  by  Morgagni.  Its 
nerve-supply  is  from  the  anterior  branch  of  the  fourth  sacral  nerve. 

The  levator  ani  proper,  which  constitutes  the  remaining  portion  of 
the  pelvic  diaphragm,  is  in  its  general  shape  an  inverted  cone,  support- 
ing the  pelvic  contents  in  its  cavity  and  allowing  the  rectum  and  prostate 
to  pass  through  its  apex.  Considering  each  lateral  half  of  the  muscle 
apart,  we  find  it  made  up  of  a  delicate  layer  of  muscular  fibres  forming 
a  thin,  curved,  and  quadrilateral  sheet,  broader  behind  than  in  front. 
Its  upper  border  is  stretched  across  the  pelvis  from  the  pubes  to  the 
spine  of  the  ischium,  arising  from  both  these  bony  points  and  from  the 
tendinous  line  of  union  of  the  pelvic  with  the  obturator  fascia,  which 
runs  antero-posteriorly  between  them.  Its  attachment  to  the  pubic 
bone  is  at  a  point  on  its  inner  surface,  near  the  middle  of  the  descending 
ramus  and  a  little  to  one  side  of  the  symphysis.  This  attachment  will 
be  found  to  vary  somewliat  in  different  dissections,  being  sometimes  a 
little  higher  or  a  little  lower  on  the  bone,  and  sometimes  on  the  cartilage 
between  the  bones.  The  muscular  fibres  may  also  be  traced  at  times  up- 
ward into  the  pelvic  fascia  above  its  junction  with  the  obturator. 

From  this  extensive  though  delicate  and  in  great  part  membranous 


12  DISEASES    OF    THE    KECTUM    AND    ANUS. 

origin,  the  fibres  proceed  downwards  and  inwards  toward  the  median 
line.  Those  most  anterior  unite  with  those  of  the  opposite  side  beneath 
the  neck  of  the  bladder,  the  prostate,  and  the  adjacent  portion  of  the 
urethra.  These  fibres  are  concealed  by  the  jjubo-prostatic  ligament  or 
anterior  fold  of  the  recto-vesical  fascia,  from  which  they  also  sometimes 
take  origin  in  part.  They  are  in  relation,  in  front,  with  the  posterior 
surface  of  the  triangular  ligament.  This  portion  is  sometimes  separated 
from  the  main  body  of  the  muscle  by  a  cellular  interval,  similar  to  those 
often  found  in  other  parts  of  this  thin  muscular  sheet. 

The  fibres  which  arise  from  the  tip  of  the  spine  of  the  ischium  are 
inserted  into  the  side  of  the  tip  of  the  coccyx;  while  the  fibres  immedi- 
ately in  front  of  these  (precoccygeal)  unite  with  those  of  the  opposite 
side  in  the  median  line  and  form  a  raphe  which  extends  from  the  point 
of  the  coccyx  to  the  posterior  border  of  the  sphincter  and  thus  complete 
the  floor  of  the  pelvis. 

The  fibres  which  arise  indirectly  from  the  upper  part  of  the  obturator 
foramen  and  from  the  brim  of  the  pelvis  by  means  of  the  pelvic  fascia, 
pass  downward  and  inward,  forming  a  curve  with  its  concavity  upwards, 
and  may  be  divided  into  vesical  and  anal.  The  vesical  pass  into  the  sides 
of  the  bladder.  The  anal  fibres  in  part  pass  backward  and  meet  behind 
the  bowel  and  in  part  blend  with  those  of  the  external  sphincter  at  its 
upper  border,  there  being  no  distinct  line  of  separation  between  the  two 
muscles. 

The  relations  of  the  levator  ani  are  of  great  surgical  importance. 
Superiorly  its  surface  is  covered  by  the  superior  pelvic  fascia  which  sepa- 
rates it  from  the  peritoneum  and  pelvic  organs.  Its  inferior  surface  is  sepa- 
rated from  the  obturator  internus  muscle  by  the  obturator  fascia,  and  be- 
neath this  is  the  ischio-rectal  fossa.  The  posterior  part  of  the  muscle  is 
in  relation  with  the  gluteus  maximus. 

The  actions  of  this  muscle  are  various.  First,  it  acts  as  a  support  to 
the  pelvic  organs,  and  antagonizes  the  diaphragm  and  abdominal  muscles 
when  they  act  upon  the  abdominal  contents.  Again,  it  prevents  the  rec- 
tum from  being  protruded,  and  raises  the  anus  and  opens  it;  being  in 
this  respect  the  direct  antagonist  of  sphincter.  By  inclosing  the  neck  of 
the  bladder  the  muscle  acts  upon  it  also,  and  in  the  act  of  defecation 
when  the  muscle  is  contracted  to  open  the  anus,  the  neck  of  the  bladder 
is  pressed  upon  and  the  urethra  closed.  In  this  way  is  explained  the 
well-known  difficulty  of  passing  urine  and  faeces  at  the  same  time.  By 
inclosing  the  bladder,  vesiculse  seminales,  prostate,  and  anus  in  its  grasp, 
the  muscle  produces  a  sympathy  among  these  parts  which  will  often  be 
found  very  distressing  in  diseases  of  the  rectum  or  after  operations  for 
their  relief — such  as  impossibility  of  micturition,  erections,  and  lancinat- 
ing pain  due  to  spasmodic  action  of  the  muscle.  It  will  often  happen 
that  after  a  complete  paralysis  by  free  division  of  both  sphincter  muscles 
in  an  operation  upon  the  rectum,  the  patient  will  still  complain  of  a 


PRACTICAL    POINTS    IN    ANATOMY    AND   PHYSIOLOGY.  13 

sharp  spasmodic  paiu  at  intervals — just  such  a  pain  as  is  caused  by  spas- 
modic contractions  of  the  sphincter.  In  such  cases  it  is  the  levator  ani 
which  is  at  fault.  The  muscle  also  aids  the  longitudinal  fibres  of  the  rec- 
tum in  their  opposition  to  the  dragging  of  the  faeces;  and  the  anal  fibres 
also  draw  the  rectum  upwards  and  forwards,  and  compress  it  on  the  sides, 
and  thus  aid  in  the  expulsion  of  its  contents. 

The  muscle  receives  a  filament  from  the  fourth  sacral  nerve  on  its 
pelvic  surface,  and  another  from  the  internal  pudic. 

Transversus  perinei. — This  also  has  an  action  in  defecation.  Its 
fibres  do  not  always  blend  with  those  of  the  opposite  side  in  the  median 
raphe,  but  the  two  muscles  are  sometimes  continuous,  traversing  the  ante- 
rior extremity  of  the  external  sphincter.  In  such  a  case  the  two  muscles 
form  a  continuous  half  ring  the  concavity  of  which  is  directed  backwards 
and  embraces  the  anterior  part  of  the  rectum,  assisting  powerfully  in  de- 
fecation by  pressing  the  anterior  against  the  posterior  wall  of  the  bowel 
in  conjunction  with  the  levator-ani  (Cruveilhier). 

Arteries. — The  rectum  is  supplied  with  blood  from  five  arteries,  one 
single  and  two  pairing. 

The  superior  haemorrhoidal  is  single  and  is  a  direct  branch  of  the 
superior  mesenteric.  It  is  the  direct  continuation  of  the  parent  trunk, 
passing  into  the  pelvis  behind  the  rectum  in  the  fold  of  the  meso-rectum 
and  dividing  into  two  branches  which  extend,  one  on  each  side  of  the 
bowel,  to  its  lower  end.  About  five  inches  from  the  anus  these  subdivide 
into  smaller  branches  about  seven  in  number,  which  pierce  the  muscular 
coat  about  two  inches  lower  down.  They  then  descend  between  the 
mucous  and  muscular  layers  at  regular  intervals  to  the  end  of  the  bowel, 
where  they  communicate  in  loops  opposite  the  internal  sphincter,  and 
anastomose  with  the  terminal  filaments  of  the  middle  and  inferior  hajmor- 
rhoidal  arteries. 

The  middle  haBraorrhoidal  arteries — one  each  side — are  not  constant 
in  their  origin,  sometimes  coming  from  the  hypogastric  or  the  inferior 
vesical,  and  sometimes  from  other  sources. 

The  inferior  haemorrhoidal  arteries — also  pairing — are  usually  given 
off  from  the  internal  pudic  near  the  point  where  it  crosses  the  tuber  ischii. 
They  cross  through  tlie  fat  of  the  ischio-rectal  fossaa  and  are  distributed 
with  the  middle  haBmorrhoidal  to  the  lowest  part  of  the  rectum  and  to 
the  anus  and  adjacent  skin. 

Veins. — There  are  three  sets  of  rectal  veins,  as  there  are  three  sets  of 
arteries,  the  sui)erior,  middle,  and  inferior;  and  these  are  so  arranged  as 
to  form  two  distinct  venous  systems,  the  one,  rectal,  and  returning  its 
blood  to  the  vena  porta;  the  other  anal,  returning  its  blood  through  the 
internal  iliac.  The  first,  or  rectal  circulation,  is  made  up  of  the  supe- 
rior haemorrhoidal  vein;  the  second,  or  anal,  is  made  up  of  the  middle 
and  inferior  haemorrhoidal  veins;  the  middle  receiving  its  blood  from  the 
anus  and  the  inferior  from  the  adjacent  integument.     The  middle  haemor- 


14: 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


rhoidal  ascends  obliquely  into  the  ischio-rectal  fossa;  the  inferior  starts 
horizontally  from  the  skin  of  the  anus  and  empties  into  the  internal 
pudic. 

The  middle  haBmorrhoidal  is  formed  from  two  venous  trunks,  one  on 
the  anterior,  the  other  on  the  posterior  aspect  of  the  rectum,  ■which  by 
anastomosing  with  the  corresponding  branches  from  the  opposite  side 
surround  the  sphincter  in  a  venous  circle.  From  this  circle  spring  the 
collateral  branches  which  by  their  successive  division  and  anastomoses 


YHM, 


^mM. 


YHE 


Fig.  4.— Rectal  veins  seen  from  wthout  (Duret).'  Amp.,  Rectal  pouch.  S.  E.,  External 
sphincter.  P.,  Skin  at  margin  of  anus  dissected  up  and  turned  back.  V.  H.  I.,  Internal  hsemor- 
rboidal  vein.    V.  H.  IL,  Middle  haemorrhoidal  vein.    V.  H.  E.,  External  haemorrholdal  vein. 

form  a  true  venous  plexus.  The  inferior  haemorrhoidal  vein  also  has  a 
plexiform  arrangement  at  its  origin,  but  its  branches  are  situated  be- 
tween the  skin  and  the  inferior  border  of  the  external  sphincter.  The 
rectal  pouch  is  not,  therefore,  supplied  with  blood  from  the  external 
haemorrhoidal  veins,  but  only  the  anus  and  the  region  of  the  sphincters. 
When,  on  the  other  hand,  the  venous  circulation  of  the  rectum  proper 


'  '•Recherches  sur  la  Pathogenie  des  Hemorrhoides.' 
December,  1879. 


Arch.  Gen.  de  Med., 


PBACnCAL    POINTS    IN    ANATt)MY    AND   PHYSIOLOGY. 


15 


is  injected  from  the  inferior  mesenteric  vein,  three  or  four  large  venous 
trunks  may  bo  seen  on  the  external  surface  of  the  rectum  ascending  on 
the  sides  and  posteriorly.  Figs.  4  and  5.  These  veins  make  their  ap- 
pearance suddenly  by  five  or  six  branches  which  perforate  the  wall  of  the 
bowel  about  three  inches  from  the  margin  of  the  anus.  If  the  rectum  be 
opened  longitudinally  and  the  mucous  membrane  dissected  up  to  a  suffi- 
cient height  (about  four  inches),  it  will  be  seen  that  these  five  or  six 
largo  veins  already  visible  on  the  outside  of  the  bowel  come  from  within; 


Fio.  5.— Rectal  veins  seen  from  within  (Duret).  M.  q.,  Mucous  membrane  dissected  up  and 
cut  away  below.  M.  cl.,  Muscular  tunic.  8p.  I.,  Internal  sphincter.  Sp.  E.,  External  sphincter. 
P.,  Slcin.  H.  I.,  Internal  hsemorrboidal  vein.  H.  M.,  Middle  hasmorrhoidal  vein.  H.  E.,  Ezt«mal 
btemorrhoidal  vein. 

and  that  they  have  already  pursued  quite  a  long  course  under  the  mu- 
cous membrane.  They  are  formed  by  collateral  branches,  and  especially 
by  about  a  dozen  primitive  branches,  which  originate  about  half  an  inch 
above  the  anus  and  ascend  in  parallel  and  flexuous  lines  for  several  cen- 
timetres to  unite  into  common  trunks.  Each  of  these  little  ascending 
brandies  has  its  origin  in  a  minute  pool  of  blood,  the  size  of  which  varies 
in  the  normal  state  from  that  of  a  grain  of  wheat  to  that  of  a  small  pea. 


16  DISEASES   OF   THE    RECTUM    AND    ANUS. 

These  little  sacs  are  arranged  in  a  circular  form  around  the  extremity 
of  the  rectum.  If  carefully  dissected,  they  may  be  seen  to  be  connected 
with  the  little  veins  before  mentioned,  and  also  with  another  little  vein 
which  perforates  the  internal  sphincter  near  its  lower  edge,  and  empties 
into  one  of  the  rudimentary  branches  of  the  external  haemorrhoidal  plexus. 
Many  of  these  little  communicating  branches  between  the  external  and 
internal  haemorrhoidal  systems  pass  through  the  substance  of  the  exter- 
nal sphincter.  It  results  from  this,  that  when  the  external  sphincter  is 
contracted,  the  anastomosis  between  the  two  systems  is  prevented. 

Verneuil  has  laid  stress  upon  the  fact  that  where  the  internal  or  su- 
perior haemorrhoidal  veins  perforate  the  rectal  wall  from  within  out- 
wards, they  pass  through  "muscular  button-holes"  surrounded  by  no 
fibrous  tissue  and  having,  therefore,  the  power  of  contracting  round  the 
vein,  closing  its  calibre,  and  preventing  the  return  of  blood  to  the  liver. 
In  this  anatomical  arrangement  he  believes  he  has  found  the  active  cause 
of  internal  haemorrhoids. 

The  disposition  of  the  rectal  veins  into  two  distinct  systems,  the  one 
internal  and  the  other  external,  is  fully  in  conformity  with  our  knowledge 
of  the  development  of  the  rectum  and  anus.  The  rectal  cul-de-sac  is  at 
first  situated  at  some  distance  from  the  perineum,  and  as  it  descends  it 
carries  with  it  its  own  proper  vascular  supply.  The  anal  depression  is  of 
necessity  provided  with  an  independent  set  of  vems,  and  when  the  rec- 
tum and  anus  are  finally  united  into  one  canal  the  two  venous  systems 
unite. 

The  internal  haemorrhoidal  veins  also  communicate  freely  with  other 
branches  of  the  internal  iliac  around  the  trigone  of  the  bladder  by  means 
of  minute  branches  from  one-half  to  one  mm.  in  diameter  which  pass 
through  the  prostate  and  vesiculae  seminales. 

Nerves. — The  nerves  of  the  rectum  and  anus  are  derived  from  both 
the  cerebro-spinal  and  sympathetic  systems.  The  former  are  branches 
from  the  sacral  plexus,  the  latter  from  the  mesenteric  and  hypogastric 
plexuses.  The  spinal  nerves  are  derived  from  the  third  and  fourth 
sacral  which  supply  visceral  branches  to  all  the  pelvic  organs,  anastomos- 
ing with  branches  from  the  sympathetic.  The  muscular  branches  from 
the  same  nerves  have  already  been  spoken  of  in  connection  with  the  in- 
dividual muscles.  The  fifth  sacral  nerve  also  sends  a  small  twig  to  the 
coccygeus.  The  posterior  branch  of  the  superficial  perineal  nerve  from 
the  internal  pudic,  supplies  the  skin  in  front  of  the  anus;  while  the  an- 
terior branch  gives  several  small  filaments  to  the  levator  ani. 

The  inferior  haemorrhoidal  branch  from  the  pudic  supplies  the  lower 
end  of  the  rectum,  the  external  sphincter,  and  the  skin  of  the  anus. 
This  nerve  may  come  direct  from  the  sacral  plexus  through  the  lesser 
sacro-sciatic  notch.  The  posterior  branches  of  the  sacral  nerves  also  sup- 
ply the  skin  over  the  coccyx  and  around  the  anus. 


PRACTICAL    POINTS    IN    ANATOMY-    AND   PHY8I0IXXJY.  17 

According  to  a  brief  contribution  of  W.  Krauso,'  the  nerves  end  in  the 
mucous  membrane  of  the  anus,  in  club-shaped  bulbs,  about  0.05  mm. 
in  diameter,  which  lie  under  the  bases  of  papillae. 

The  tonic  contraction  of  the  external  sphincter  muscle  is,  in  part  at 
least,  due  to  the  influence  of  a  nerve-centre  located  in  the  lumbar  region 
of  the  spinal  cord.'  If  the  nerve  connection  of  the  sphincter  with  the 
spinal  cord  be  severed,  relaxation  of  the  muscle  takes  place.  The  fact 
that  division  of  the  cord  in  the  dorsal  region  does  not  affect  the  sphincter, 
except  temporarily  by  shock  or  depression,  proves  that  this  centre  is  not 
located  above  the  lumbar  region.  This  nerve-centre  is  subject  to  various 
influences;  and  the  sphincter  may  either  be  relaxed,  or  its  tonic  contrac- 
tion increased,  by  local  stimulation,  or  by  the  influence  of  the  will  or 
emotions. 

Though  the  dependence  of  the  sphincter  for  its  tonic  contraction 
upon  the  lumbar  nerve-centre  seems  so  great,  still  it  is  not  absolute.  In 
the  case  of  a  man  in  whom  the  sacral  nerves  were  entirely  paralyzed  by  an 
injury,  and  in  Avhom,  therefore,  there  was  no  nerve  connection  with  the 
lumbar  centre  except  perhaps  through  the  sympathetic,  Gower*  observed 
the  maintenance  of  a  certain  amount  of  tonic  contraction,  which  could 
be  inhibited  and  relaxation  produced  by  stimulation  of  the  mucous 
membrane  of  the  rectum  and  anus.  From  this  it  would  appear  that  the 
tonic  contraction  of  the  sphincter,  as  is  known  to  be  the  case  in  the 
arterial  system,  is  habitually  dependent  on  a  spinal  centre,  but  may, 
nevertheless,  exist  without  the  action  of  that  centre.  The  paralysis  of  the 
muscle  which  follows  brain  lesions  is  probably  due  merely  to  inhibition  of 
the  spinal  centre,  and  not  to  the  injury  of  any  centre  located  in  the  cere- 
brum. ' 

The  distribution  of  the  spinal  nerves  serves  to  explain  many  of  the 
reflex  and  so-called  anomalous  symptoms  of  pain  which  are  encountered 
in  diseases  of  the  rectum  and  anus.     Brodie*  relates  an  instructive  case 


'  Esmarch,  op.  cit.,  p.  10. 

'Masius:  Bull,  de  I'Acad.  Royal  de  Belgique,  xxiv.  (1867),  p.  812.  (Foster's 
Physiologj',  p.  387.) 

*  Proc.  Roy.  Soc.  (1877),  p.  77. 

<  Foster's  Physiology,  Phila.,  1880,  p.  388. 

'  A  lady  consulted  me,  says  Mr.  Brodie,  concerning  a  pain  to  which  she  had 
been  for  some  time  subject,  beginning  in  the  left  ankle,  and  extending  along  the 
instep  toward  the  little  toe,  and  also  into  the  sole  of  the  foot.  The  pain  was 
described  as  being  very  severe.  It  was  unattended  by  swelling  or  redness  of  the 
skin,  but  the  foot  was  tender.  She  laboretl  also  under  internal  piles,  which  pro- 
truded externally  when  she  was  at  the  water-closet,  at  the  same  time  that  she 
lost  from  theni  sometimes  a  larger  and  sometimes  a  smaller  quantity  of  blood. 
On  a  more  particular  inquiry,  I  learned  that  she  was  free  from  pain  in  the  foot 
in  the  morning;  -that  the  pain  attacked  her  as  soon  as  the  first  evacuation  of  the 
bowels  had  occasioned  a  protrusion  of  the  piles;  that  it  was  especially  induced 
by  an  evacuation  of  hard  fseces;  and  that,  if  she  {lassed  a  day  without  any  evacu- 
2 


18 


DISEASES    OF    THE    RECTUM    AND    ANCS. 


of  pain  in  the  foot  over  the  distribution  of  the  sciatic  which  was  cured 
by  curing  prolapsing  haemorrhoids — the  irritation  being  primarily  at  the 
termination  of  the  internal  pudic,  and  conveyed  thence  to  the  sacral 
plexus,  to  be  carried  to  the  termination  of  the  great  sciatic.  In  the  same 
way  a  fissure  of  the  annus  may  cause  pain  in  the  lumbar  and  iliac  regions; 
pain,  loss  of  sensation,  and  cramps  in  the  legs;  and  symptoms  of  bladder 
and  urethral  disease,  besides  more  general  nervous  phenomena.  See 
Fig.  6. 

The  chief  nerve  supply  of  the  rectum  is  at  the  lower  portion  and 
around  the  anus — the  middle  and  upper  portions  possessing  very  little 
sensibility;  so  little  in  fact  that  the  gravest  diseases,  such  as  cancer  or 
ulceration,  may  exist  and  not  manifest  themselves  by  pain.  This  also 
explains  how  large  masses  of  faeces  may  accumulate  in  the  rectal  pouch 


Fig.  C— Diagrammatic  view  of  nerves  of  anus.  (Hilton.)  a,  Ulcer  on  sphincter;  6,  the  fila- 
ments of  two  nerves  are  exposed  on  the  ulcer,  the  one  a  sensory,  and  the  other  motor,  both  at- 
tached to  the  spinal  marrow,  thus  constituting  an  excito-motory  apparatus;  c,  levator  ani;  d, 
transversus  perinei. 

without  causing  suffering.  Puncti^ring  the  bladder  through  the  rectum 
is  not  a  painful  operation,  and  applications  of  strong  acids  to  the  mucous 
membrane  will  cause  little  suffering  if  the  skin  be  properly  protected. 
Exactly  the  opposite  condition  obtains  at  the  anus,  the  extreme  sensibility 
of  which  is  Avell  known. 

The  pelvic  plexuses  of  the  sympathetic  are  placed  one  on  either  side 
of  the  rectum  and  vagina.  Each  is  composed  of  prolongations  from  the 
hypogastric  plexus  above,  united  with  branches  from  the  sacral  ganglia. 


ation  at  all,  the  pain  in  the  foot  never  troubled  lier.  Having  taken  all  these 
facts  into  consideration,  I  prescribed  for  her  the  daily  use  of  a  lavement  of  cold 
water;  that  she  should  take  the  Ward's  paste  (confectio  piperis  composita)  three 
times  daily,  and  some  lenitive  electuary  at  bedtime.  After  having  persevered  in 
this  plan  for  a  space  of  six  weeks,  she  called  on  me  again.  The  piles  had  now 
ceased  to  bleed,  and  in  other  respects  gave  her  scarcely  any  inconvenience.  The 
pain  in  the  foot  had  entirely  left  her.  She  observed  that ,  in  proportion  as  the 
symptoms  produced  by  the  piles  had  abated,  the  pain  in  the  foot  had  abated  also. 
Medical  Gazette,  vol.  v. 


PBACTICAL    POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  19 

The  spinal  branches  to  the  sympathetic  are  mostly  from  the  third  and 
fonrth  sacral  nerves.  From  the  back  part  of  the  plexus  thus  formed  are 
given  off  the  inferior  haemorrhoidal  nerves,  which  join  with  the  superior 
haemorrhoidal  from  the  inferior  mesenteric  artery  and  perforate  the 
rectal  wall. 

Lymphatics. — The  lymphatic  vessels  of  the  rectum  are  arranged  like 
those  of  the  intestine  generally,  in  two  layers;  one  beneath  the  perito- 
neum; and  one  between  the  mucous  and  muscular  coats.  Immediately 
after  leaving  the  bowel  some  of  the  vessels  pass  through  small  adjacent 
glands,  and  all  finally  enter  the  glands  in  the  hollow  of  the  sacrum,  or 
those  higher  up  in  the  loin. 

But  just  as  there  is  an  internal  and  external  system  of  veins,  one 
proper  to  the  rectum,  the  other  to  the  anus,  so  is  there  another  lymphatic 
system  which  comes  from  the  integument  around  the  anus,  and  passes  to 
the  glands  in  the  groin;  and  these  two  sets  of  vessels  freely  communicate 
with  each  other.  A  knowledge  of  this  fact  is  of  importance  in  the  diag- 
nosis of  the  cancer  of  the  rectum;  and  the  glands  which  are  deep  in  the 
pelvis  along  the  sacrum  should  always  be  felt  for,  as  well  as  those  located 
in  the  groin. 

Defecation. — A  study  of  the  anatomy  of  the  rectum  would  not  be 
complete  without  some  reference  to  its  physiological  functions.  We  shall, 
therefore,  in  this  place  consider  the  function  of  defecation,  postponing 
the  question  of  absorption  until  we  consider  that  of  rectal  alimentation. 

In  regard  to  defecation  the  question  at  once  arises,  how,  after  destruc- 
tion of  the  lower  end  of  the  rectum,  or  paralysis  of  the  sphincters,  there 
still  remains  a  certain  amount  of  control  over  the  evacuations?  Such  an 
injury  is  often  only  noticeable  through  a  constant  discharge  of  rectal 
mucus,  and  an  occasional  involuntary  escape  of  fluid  fasces  when  the 
patient  is  suffering  from  diarrhoea.  This  leads  naturally  to  a  considera- 
tion of  the  third  or  superior  sphincter  muscle,'  whose  existence  has  been 
supposed  to  account  for  such  control  of  the  evacuations  as  exists  in  this 
condition. 

'Gosselin:  "  Retr^issements  Syphilitiqueadu  Rectum."  Arch.  G^nl.du  Med., 
1854,  p.  668. 

Henle:  '•  Handb.  dersystemat,  Anat.  des  Menschen,"  1873,  Bd.  ii. 

Hyrtl:  "Handb.  der  topogr.  Anat.,"  Wien,  1857,  Bd.  ii.,  pp.  108,  109. 

Sappey:   "  Traite  d' Anat.  Descriptive,"  Paris,  1874,  t.  iv. 

Chadwick:  "Trans,  of  the  Am.  Gynaecol.  Soc.,"  ii.,  1877. 

Petrequin:  "  Traite  d' Anat.  Topogr.  Med.-Chirurg.,"  etc.,  2meM.,  Paris,  1857, 
p.  414. 

Houston :  "  Dublin  Hosp.  Rep.,"  v.,  1830. 

O'Beime:  "  New  Views  of  the  Process  of  Defecation,"  etc.,  Dublin.  1833. 

Bushe:  "Treatise  on  the  Malformations,  Injuries, and  Diseases  of  the  Rectum 
and  ^Vnus,"  New  York,  1837. 

Kohlrausch:   "Anat.  u.  Physiol,  der Beckenorgane,"  Leipzig,  1854. 

Rosswinkler:   "Wien.  med.  Woch.,"  1852,  p.  4iJ5. 

Foster:  "  Text- Book  of  Physiology,"  Philadelphia,  1880,  p.  887. 


20  DISEASES    OF   THE   EECTUM    AND    AND8. 

It  is  now  about  half  a  century  since  Nelaton  first  described  the  third 
sphincter  muscle,  and,  in  spite  of  all  that  has  been  written  concerning  it 
since  that  time,  it  is  only  recently  that  Van  Bureu '  summed  up  the 
general  knowledge  of  anatomists  and  surgeons  in  regard  to  it,  by 
characterizing  it  as  an  organ  to  which  anatomy  and  physiology  had  been 
equally  unsuccessful  in  assigning  either  certainty  of  location  or  certainty 
-  of  function.  For  the  original  description  of  the  muscle  by  JS'elaton  we 
are  indebted  to  Velpeau,  who  writes  that  he  has  verified  the  existence  of 
a  sort  of  sphincter  of  the  rectum,  lately  discovered  by  Nelaton,  and  goes 
on  to  say  that  it  is  a  muscular  ring  situated  about  four  inches  above  the 
anus,  just  in  the  place  where  retractions  of  £he  rectum  are  most  often 
found.  If,  after  turning  the  rectum  so  that  its  mucous  surface  is  exter- 
nal, it  is  moderately  distended  by  insufflation,  the  muscle  will  be  seen  to 
be  made  up  of  fibres  collected  into  bundles.  Its  breadth  is  from  six  to 
seven  lines  in  front,  and  about  an  inch  behind.  Its  thickness,  on  the 
contrary,  is  much  greater  in  front,  where  the  fibres  appear  to  be  collected 
in  the  angle  which  corresponds  to  the  union  of  the  first  and  second 
curves  of  the  rectum,  while  behind  they  are  scattered  over  its  convexity. 
After  thus  adopting  the  description  of  Nelaton,  Velpeau  "  brings  out  one 
other  anatomical  point — the  attachment  of  the  muscle  posteriorly  to  the 
front  of  the  sacrum.  The  functions  ascribed  to  the  muscle  by  Xelaton 
were  those  of  keeping  the  rectum  empty  until  a  short  time  before  the  act 
;of  defecation;  separating  the  fsecal  mass  and  preventing  its  regurgitation 
during  defecation;  and  of  opposing  the  continuous  and  involuntary 
escape  of  fseces  after  the  destruction  of  the  lower  sphincters. 

Hyrtl  refers  to  this  description,  and  himself  describes  the  muscle  as 
being  six  or  seven  lines  in  breadth  anteriorly  and  an  inch  posteriorly,  but 
does  not  always  find  it  present.  He  also  in  one  case  demonstrated  the 
attachment  to  the  sacrum.  Sappey  admits  its  frequent  existence,  and 
locates  it  at  the  level  of  the  base  of  the  prostate,  in  the  middle  portion  of 
the  rectum,  six,  seven,  eight,  or  sometimes  nine  centimetres  from  the 
anus.  It  never  completely  surrounds  the  rectum,  but  only  one-half  or 
two-thirds  of  its  circumference;  and  it  appears  to  him  to  be  caused  by  a 
grouping  of  the  circular  muscular  fibres,  some  being  gathered  from  below 
upward,  and  others  from  above  downward,  to  the  same  point.  Its 
breadth  is  one  centimetre,  and  its  thickness  two  or  three  millimetres. 
Situated  sometimes  in  front,  sometimes  behind,  and  again  laterally  or 
antero-laterally;  it  is  constant  in  nothing  except  its  direction  perpen- 
dicular to  the  axis  of  the  bowel.  In  place  of  one,  he  has  sometimes 
found  two  bands  at  opposite  points  and  different  levels,  and  in  one  speci- 
men which  he  has  preserved  there  were  three.  Henle  adopts  Sappey's 
description  in  the  main.     Petrequin  found  the  muscle  irregularly  oblique, 

'  "  On  Phantom  Stricture,"  etc.,  Am.  Jour,  of  the  Med.  Sci.,  October,  1879. 
*  Velpeau:  "Traite  d'Anat.  Chirurg.,"  3me  ed.,  1837,  introduction,  p.  39. 


PRACTICAL    POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  21 

less  marked  in  the  front  wall  than  in  the  back,  and  consisting  of  a  collec- 
tiou  of  weak  bands  of  fibres.  Chadwick  asserts  that  no  distinct  muscle 
exists,  but  describes  in  place  of  it  two  agglomerations  of  the  circular 
muscular  fibres,  one  on  the  anterior  and  one  on  the  posterior  wall, 
corresponding  to  two  semi-circular  constrictions  which  may  be  felt  by 
digital  examination,  and  whose  effect  is  to  give  the  rectum  its  sigmoid 
curve. 

The  third  sphincter  muscle  and  the  yalves  of  mucous  membrane  in 
the  rectum  are  not,  as  might  be  supposed,  one  and  the  same  thing, 
though  it  is  true  that  they  have  become  almost  hopelessly  confounded  in 
surgical  and  anatomical  literature,  and  are  often  spoken  of  as  identical. 
As  far  as  possible,  we  shall  try  to  consider  them  separately,  without  doing 
violence  to  the  text  of  the  authorities.  The  valves  of  the  rectum  (we  use 
the  word  simply  as  expressing  the  folds  of  mucous  membrane)  were  first 
described  by  Houston  at  about  the  same  time  that  Nelaton  described  the 
superior  sphincter;  and  it  is  worth  remembering  that  the  two  authors 
were  writing  about  two  entirely  different  things,  and  two  things  which 
stood  in  no  necessary  relation  to  each  other,  so  far  as  we  may  judge  from 
their  descriptions.  Houston's  method  of  preparation  was  by  filling  and 
distending  the  gut  with  spirit  before  its  removal  from  the  body,  and  then 
laying  it  open  longitudinally.  He  states  that  the  folds  disappear  if  the 
bowel  is  first  removed  from  its  natural  position  and  then  distended,  but 
that  they  may  be  seen  in  the  natural  condition  of  the  parts  soon 
after  death  before  the  tonic  contraction  has  disappeared;  and  that 
they  are  then  found  to  overlap  each  other  so  effectually  as  to  require 
considerable  manoeuvering  in  order  to  pass  a  bougie  or  the  finger  along 
the  bowel.  It  is  also  remarked  that  this  is  just  the  arrangement  neces- 
sary to  prevent  the  faeces  from  urging  their  way  toward  the  anus,  where 
their  presence  would  excite  a  constant  sensation  demanding  their  dis- 
charge. 

According  to  this  first  and  clearest  of  all  the  descriptions — for  the 
whole  article  is  written  with  a  force  and  clearness  of  style  which  have 
perhaps  had  an  undue  weight  in  disarming  criticism  as  to  the  facts — the 
valves  exist  in  all  persons,  but  vary  much  in  different  individuals  as  to 
location  and  number.  Three  is  the  average  number,  though  sometimes 
four,  and  again  only  two  are  well  marked.  The  largest  and  most  con- 
stant is  about  three  inches  from  the  anus,  opposite  the  base  of  the  blad- 
der; the  next  most  constant  is  at  the  upper  end  of  the  rectum;  the  tliird 
is  about  midway  between  these;  and  the  fourth,  or  the  one  most  rarely 
present,  is  attached  to  the  side  of  the  gut  about  an  inch  above  the  anus. 
The  first  one  generally  projects  from  the  right  wall;  the  one  next  above 
from  the  left;  the  uppermost  from  the  right;  and  the  one  nearest  the 
anus,  when  present,  from  fhe  left  and  posterior  wall;  the  arrangement 
being  such,  in  spite  of  variations,  as  to  form  a  spiral  tract  down  the  gut. 
The  folds  are  described  as  somihinar  in  form,  with  the  convex  border 


22  DISEASES   OF   THE   RECTUM    AND    ANUS. 

attached  to  the  side  of  the  bowel,  and  occupying  from  one-third  to  one- 
half  of  its  circumference.  The  surfaces  are  sometimes  horizontal,  but 
more  often  oblique,  with  the  sharp,  concave,  floating  margin  generally 
directed  a  little  upward.  In  breadth  they  vary  from  one-half  to  three- 
quarters  of  an  inch  or  more  in  the  distended  state  of  the  gut;  and  they 
are  said  to  be  composed  of  a  duplicature  of  mucous  membrane  inclosing 
some  cellular  tissue  and  a  few  of  the  circular  muscular  fibres. 

The  palpable  weak  points  in  Houston's  article  were  very  soon  pointed 
out  by  O'Beirne,  in  a  work  of  marked  and  almost  amusing  originality. 
The  views  were  indeed  "  new,"  but  they  are  to-day  accepted  in  many 
points  by  those  whose  judgment  is  worthy  of  the  most  confidence  in 
these  matters.  O'Beirne  seems  rather  to  regret  that  he  is  unable  to 
accept  Houston's  statements  as  to  an  anatomical  condition  which  would 
account  so  fully  and  so  easily  for  the  physiological  emptiness  of  the 
rectum  and  fulness  of  the  sigmoid  flexure  on  which  his  own  views 
depend;  but  nevertheless  he  sets  himself  to  the  task  of  demolishing  them 
with  great  vigor  and  considerable  success.  Although  he  believes  the 
rectum  to  be  normally  empty,  except  just  at  the  time  of  defecation,  he 
believes  that  condition  to  depend  upon  the  anatomical  arrangement  of 
the  sigmoid  flexure,  joined  with  the  narrowing  of  the  upper  end  of  the 
rectum,  which  is  entirely  independent  of  any  folds  of  mucous  membrane. 
He  not  only  denies  the  existence  of  any  such  folds,  but  states  flatly  that 
Houston  is  altogether  incorrect  in  his  statement  that  Cloquet  or  any 
other  anatomist  before  his  time  makes  even  the  slightest  allusion  to 
them. '  He  believes  the  folds  to  have  been  produced  by  the  method  of 
making  the  preparations — distending  and  hardening  all  the  parts  with 
spirit  before  making  the  incision— and  asserts  that  this  method  is  any- 
thing but  natural,  and  nothing  more  or  less  than  an  attempt  to  exhibit 
natural  appearances  by  placing  the  parts  fn  an  unnatural  situation — such 
a  situation,  indeed,  as  is  not  known  to  be  necessary  for  the  exhibition  of 
the  valvulge  conniventes  or  any  other  valves  of  the  body.  He  meets  the 
statement,  that  by  the  ordinary  procedure  of  distending  the  rectum  after 
removal  from  the  body  the  valves  are  made  to  disappear,  by  the  question, 
why,  if  such  valves  really  exist,  and  if  muscular  fibres  enter  into  their 

*  Regarding  this  question  of  fact,  it  may  be  well  to  quote  Cloquet's  description 
from  Bushe,  op.  cit.,  p.  60:  "The  inner  sui'face  of  the  rectum  is  commonly 
smooth  in  its  upper  half,  but  in  the  lower  there  are  observed  some  parallel  longi- 
tudinal wrinkles,  which  are  thicker  near  the  anus,  and  are  variable  in  length. 
These  wrinkles,  whose  number  varies  from  four  to  ten  or  twelve,  and  which  are 
called  the  columns  of  the  rectum,  are  formed  by  the  mucous  membrane  and  the 
layer  of  the  subjacent  cellular  tissue.  Between  these  columns  there  are  almost 
always  to  be  found  membranous  semilunar  folds,  more  or  less  numerous,  oblique 
or  transverse,  of  which  the  floating  edge  is  directed  from  below  upward  toward 
the  cavity  of  the  intestine.  These  folds  form  a  kind  of  lacuna?,  of  which  the 
bottom  is  narrow  and  directed  downward,"  It  seems  evident  that  the  sinuses  of 
Morgagni  are  here  referred  to. 


PRACTICAL    POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  23 

structure,  they  should  not  be  discoverable  at  any  time  after  death,  or  in 
any  state  of  the  intestine — a  question  very  difficult  of  solution. 

Four  years  later,  the  voice  of  a  New  York  surgeon  is  raised  against 
these  folds,  and  in  almost  the  same  language  as  O'Beirne's,  though  from 
an  entirely  independent  stand-point.  Bushe  declares  that  he  has  never, 
in  the  living  body,  been  able  to  detect  any  valve  of  such  firmness,  and 
capable  of  exerting  any  such  influence  upon  the  descent  of  the  faeces  as 
Houston  describes,  though  he  has  frequently  met  with  accidental  folds 
produced  by  the  partial  contraction  of  the  bowel;  and  the  proof  that 
they  are  accidental  is  that,  in  the  same  subject,  he  has  on  different  days 
found  them  to  occupy  different  situations,  but  always  they  were  unresist- 
ing and  easily  displaced  by  the  extremity  of  the  finger.  He  points  out 
that,  by  the  method  of  hardening  the  rectum  after  distending  it  with 
spirit,  these  accidental  folds  are  rendered  permanent  by  the  induration 
resulting  from  the  action  of  the  alcohol;  and  that,  by  the  method  of 
inflation  and  drying,  the  projections  resembling  valves  are  produced  by 
the  angles  formed  by  the  setting  of  the  intestine  during  the  process  of 
desiccation. 

Kohlrausch  describes  and  figures  one  important  fold,  the  plica  transver- 
salis  recti,  which  he  locates  at  the  same  point  as  Houston's  most  constant 
one,  projecting  well  into  the  lumen  of  the  bowel  from  the  right  side. 
It  forms  rather  more  than  a  semicircle,  and  runs  further  on  the  anterior 
than  on  the  posterior  wall.  Here  also  we  meet  the  direct  statement  that 
this  fold  is  now  known  as  the  sphincter  ani  tertius,  though  Kohlrausch 
does  not  consider  such  a  title  justified  by  the  anatomical  condition,  inas- 
much as  the  circular  muscular  fibres  do  not  enter  into  its  texture,  and 
are  not  more  developed  here  than  elsewhere.  For,  though  both  these 
things  may  happen,  as  a  rule  l]|either  is  the  case. 

Sappey  says  he  has  found  in  the  empty  state  various  folds  of  the 
mucous  membrane,  but  that  these  have  no  determinate  direction,  and 
are  generally  only  slightly  marked.  Three  times  only,  in  thirty  recta 
which  he  examined,  has  he  met  with  anything  which  at  all  answered 
to  Kohlrausch's  plica  transversalis,  or  to  Houston's  chief  valve.  There 
is  nothing  to  prove  that  they  persist  when  the  rectum  is  full;  on  the 
contrary,  it  is  probable  that  they  are  effaced  by  the  simple  fact  of  disten- 
tion of  the  lattex,  at  least  in  great  part.  The  name  of  valve  is  not,  there- 
fore, applicable  to  them,  and,  admitting  even  that  it  might  be  used  by 
one  of  those  abuses  of  language  so  frequent  in  anatomy,  Houston  would 
still  incur  the  discredit  of  having  presented  as  normal  a  fact  which  is 
only  observed  very  exceptionally. 

Henle  divides  the  valves  into  two  varieties,  the  temporary  and  the 
permanent.  Of  the  former,  he  describes  several,  which  may  be  present 
or  absent  in  the  same  individual  at  different  times  or  in  different  states 
of  the  bowel.  Of  the  permanent  variety,  there  is  only  one — the  plica 
tranversalis — and  this  one  is  only  present  ;n  a  minority  of  subjects. 


24  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Hyrtl  describes  two  folds,  both  constant:  one  on  the  right  wall  lower 
down,  and  one  on  the  opposite  side.  Rosswinkler  also  describes  two 
folds,  but  locates  them  on  opposite  sides  to  those  of  Hyrtl. 

There  would  be  little  profit  in  following  these  descriptions  of  differ- 
ent writers,  each  of  them  an  authority  on  the  subject  treated,  any  fur- 
ther; '  and  so  far  as  we  have  gone,  we  have  carefully  endeavored  to  avoid 
any  violence  to  the  meaning  of  the  text  in  thus  separating  the  thicken- 
ing of  the  muscular  fibres,  which  can  alone  constitute  a  sphincter,  from 
the  projections  and  redundancies  of  the  mucous  membrane  which  Hous- 
ton first  described  under  the  name  of  valves.  It  will  readily  be  seen, 
that  Van  Buren  was  correct  in  speaking  of  the  third  sphincter  as  an 
organ  to  which  anatomy  and  physiology  had  been  equally  unsuccessful  in 
assigning  certainty  of  location,  for  we  have  seen  it  described,  on  equally 
good  authority,  as  both  mucous  membrane  and  muscle;  as  on  all  sides 
of  the  rectum,  and  at  almost  all  distances  between  two  and  four  inches 
from  the  anus;  as  single,  double,  and  triple;  as  composed  of  mucous 
membrane  and  cellular  tissue  without  muscular  fibre,  and  of  well-marked 
muscular  bands  located  at  the  base  of  the  mucous  folds,  and  extending^ 
into  their  substance.  From  these  very  differences,  perhaps,  the  true 
anatomy  of  the  part  may  best  be  deduced.  It  is  the  old  question  of  the 
gold  and  silver  shield.  There  are  bands  of  the  circular  muscular  fibres 
of  the  rectum  located  at  various  points  in  its  upper  portion.  These  bands 
are  more  or  less  developed  in  different  subjects,  and  are  also  found  in  no 
constant  location;  being  sometimes  lower  or  higher,  and  sometimes  more- 
marked  on  the  anterior  or  again  on  the  posterior  wall.  There  are  also 
found  various  folds  and  duplicatures  of  the  mucous  membrane,  which 
stand  in  no  constant  relation  to  the  thickened  portions  of  the  muscular 
fibre,  and  have  no  definite  or  constant  situation,  but  may  alter  their 
shape  with  the  varying  condition  of  the  bowel,  and  are  found  at  different 
points  in  different  subjects.  These  folds  vary  also  in  their  structure  in 
different  people,  being  larger  and  firmer  in  some  than  in  others,  and  oc- 
casionally containing  a  few  fibres  of  the  circular  muscle  of  the  bowel. 

This  is  also  the  conclusion  reached  by  Gosselin,  who  says:  '*I  do  not 
find  the  line  of  demarcation  (between  the  upper  and  middle  portions  of 
the  rectum)  established  by  a  special  sphincter  analogous  to  that  which 
some  authors  have  indicated  by  the  name  of  sphincter  superior.  I  am 
convinced,  indeed,  by  the  examination  of  a  large  number  of  specimens 
that  the  sphincter  does  not  exist  as  an  isolated  muscle,  and  that,  when 
we  are  led  to  admit  its  existence,  we  have  to  do  with  subjects  in  whom 
the  bands  of  the  circular  layer  are  more  developed  than  in  others.     I 

'  Morgagni  ("  De  Sedibus  et  Causis  Morborum  ")  says  he  found  valves  in  two 
subjects,  situated  about  an  inch  above  the  anus,  in  one  of  a  circular,  in  the  other 
of  a  crucial  form.  The  references  of  Portal  ("  Anat.  Med."),  Glisson,  and  Boyer 
"  Traite  d'Anat.,"'  Paris,  1815,  t.  iv.,  p.  377)  probably  all  refer  to  the  sinuses  of 
Morgagni. 


PBACTICAL   POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  25 

have  often  met  this  isolated  development  of  some  of  the  circular  fibres, 
but  it  is  by  no  means  always  present,  and  for  this  reason  the  superior 
sphincter  has  not  always  been  found  by  those  who  have  searched  for  it. 
When  it  exists,  it  is  at  a  variable  height,  sometimes  between  the  middle 
and  upper  portions,  sometimes  at  some  part  of  the  circumference  of 
the  latter,  or  at  its  very  upper  portion;  and  I  explain  in  this  way  why 
O'Beime  has  placed  his  superior  sphincter  at  the  junction  of  the  rec- 
tum with  the  sigmoid  flexure,  while  N^laton  has  placed  his  lower  down, 
without  assigning  it  a  determinate  position.'* 

It  will  be  remembered  that  Hyrtl  argued  backward  from  what  he  con- 
sidered the  physiology  of  the  rectum  to  the  existence  of  a  third*sphinc- 
ter;  and  that  Houston,  in  describing  the  valves  of  membrane,  asserts  t'bat 
such  an  arrangement  as  he  discovered  was  just  the  one  which  was  a  pos- 
teriori probable,  and  which  best  accounted  for  the  accepted  theories  of 
the  physiology  of  defecation.  Nelaton,  too,  though  he  described  the 
muscle  before  he  gave  it  an  action,  assigns  to  it  the  same  function  as 
Houston  does  to  his  folds,  and  as  Hyrtl  believed  it  must  of  necessity  pos- 
sess. It  is  plain  that  each  was  led  by  a  certain  chain  of  reasoning  to  be- 
lieve in  the  existence  of  an  obstruction  to  the  passage  of  fasces  from  the 
sigmoid  flexure  above  to  the  rectum  below;  and  that  two  of  them  found  it 
in  the  muscular  structure,  and  the  third  in  the  mucous  membrane  of  the 
bowel.  The  facts  upon  which  the  necessity  for  a  superior  sphincter  are 
supposed  to  rest  are  briefly  these:  the  normally  empty  state  of  the  rec- 
tum, and  the  ability  to  retain  both  wind  and  motion  after  destruc- 
tion of  the  anus  and  its  muscles.  The  force  of  this  line  of  argument 
cannot  be  disputed,  but  were  some  other  reasonable  explanation  found 
for  these  two  facts  than  the  existence  of  a  third  muscle,  that  muscle 
would  soon  be  dropped  from  the  descriptions  of  the  anatomy  of  this  part. 
The  whole  tendency  of  the  physiology  of  the  day  is  to  furnish  such  an 
explanation. 

The  ''new  views"  of  O'Beime  with  regard  to  the  process  of  defeca- 
tion were  simply  as  follows:  The  repeated  descent  of  faecal  masses  causes 
the  sigmoid  flexure  to  become  distended,  and  to  ascend  from  its  posi- 
tion in  the  cavity  of  the  true  pelvis  into  the  left  iliac  fossa.  When  this 
occurs,  the  flexure,  in  proportion  to  the  rapidity  and  degree  of  its  disten- 
tion, begins  to  turn  upon  the  contracted  rectum  as  upon  a  fixed  point, 
until  at  length,  like  the  stomach,  it  directs  its  greater  arch  forward  and 
upward,  and  its  lesser  backward  and  downward.  By  this  movement,  the 
contents  are  brought  somewhat  perpendicular  to,  and  so  as  to  press  di- 
rectly upon  the  upjier  extremity  of  the  contracted  rectum.  But  as  the 
mere  weight  is  insufficient  to  force  a  passage  downward,  and  as  this  end 
cannot  be  accomplished  either  by  such  gentle  pressure  as  that  exerted  by 
the  alternate  contraction  of  the  diaphragm  and  the  abdominal  muscles  in 
ordinary  respiration,  or  by  the  efforts  of  the  flexure  itself,  in  consequence 
of  its  muscular  power  being  so  inferior  to  that  of  the  rectum;  the  faeces 


26  DISEASES    OF    THE    RECTUM    AND   ANUS. 

are  compelled  to  remain  stationary  until  such  time  as  the  increased  accu- 
mulation and  distention  produce  a  sense  of  uneasiness  sufficient  to  call 
into  action  those  great  expulsive  agents,  the  diaphragm  and  abdominal 
muscles.  These  muscles,  instead  of  acting  alternately,  now  act  simul- 
taneously, compress  the  abdomen  and  its  contents  on  all  sides,  urge  the 
free  and  floating  mass  of  small  intestine  downward  and  even  into  the 
cavity  of  the  pelvis,  so  as  to  press  forcibly  not  only  upon  the  sigmoid 
flexure,  but  also  upon  the  caecum  and  urinary  bladder.  By  these  means, 
the  contents  of  the  distended  flexure  are  acted  upon  in  every  direction, 
and  so  as  to  be  impelled  against  the  upper  annulus  of  the  contracted 
rectum,  with  a  force  sufficient  to  compel  its  parietes  to  separate  and 
afford  a  passage.  The  nisus  now  ceases,  but  as  soon  as  the  rectum  be- 
comes filled,  it  is  aroused  to  make  an  expulsive  effort  by  which  its  contents 
are  driven  or  impacted  into  its  pouch.  Here  they  produce  a  great  sense 
of  weight  and  uneasiness  in  the  perinaeum,  an  urgent  desire  to  go  to 
stool,  and  a  still  stronger  nisus,  by  which  the  sphincters  are  forced  open 
and  dilated,  and  the  final  expulsion  of.  the  faeces  is  effected.  This  rea- 
soning, it  will  be  seen,  is  entirely  based  upon  the  normal  empty  and  con- 
tracted state  of  the  rectum,  which  O'Beirne  not  only  states  to  be  a  clin- 
ical fact  capable  of  easy  demonstration,  but  gives  many  reasons  for,  the 
chief  being  the  great  relative  thickness  of  its  muscular  wall.  He  clearly 
pointed  out  also  (what  has  been  frequently  verified  since,  and  especially 
by  those  who  have  passed  the  hand  into  the  sigmoid  flexure  of  the  liv- 
ing subject)  that  the  upper  extremity  of  the  rectum  was  absolutely  the 
smallest  part  of  this  portion  of  the  bowel;  but  that  nothing  of  the  nature 
of  a  sphincter  muscle,  located  at  this  point  or  near  it,  entered  into  his 
calculation  any  more  than  did  the  folds  of  mucous  membrane. 

Compare,  now,  these  teachings  of  O'Beirne's,  in  1833,  which  we  have 
already  said  are  to-day  accepted  by  those  who  have  the  best  right  to 
judge  of  these  matters,  with  those  of  Foster,  in  1880.  He  says  the 
faeces,  in  their  passage  through  the  colon,  are  lodged  in  the  sacculi  dur- 
ing the  pauses  between  the  peristaltic  waves.  Arrived  at  the  sigmoid 
flexure,  they  are  supported  by  the  bladder  and  the  sacrum,  so  that  they 
do  not  press  on  the  sphincter  ani.  Defecation  is  a  composite  act,  being 
superficially  the  result  of  an  effort  of  the  will,  and  yet  carried  out 
by  means  of  an  involuntary  mechanism.  The  voluntary  effort  is  com- 
posed of  two  factors — a  pressure  effect  produced  by  the  contraction  of 
the  abdominal  muscles,  and  a  relaxation  of  the  sphincter  ani  muscle.  By 
the  pressure  of  the  abdominal  muscles  the  contents  of  the  descending 
colon  are  driven  onward  into  the  rectum,  but  the  sigmoil  flexure  itself 
is  shielded  by  its  situation  from  the  direct  force  of  this  pressure,  and  a 
body  introduced  joer  anum  into  the  empty  rectum  is  not  affected  by  even 
forcible  contraction  of  the  abdominal  muscles.  The  sphincter  muscle 
guarding  the  anus  is  habitually  in  a  state  of  tonic  contraction,  capable 
of  being  increased  or  diminished  by  a  stimulus  applied  either  internally 


PKACTICAL    POINTS    IN    ANATOMY    AND    PHYSIOLOGY.  27 

or  externally  to  the  anus.  This  tonic  contraction  is  due,  in  part  at  least, 
to  the  action  of  a  nervous  centre  situated  in  the  lumbar  portion  of  the 
spinal  cord.  3y  the  action  of  the  will,  by  emotions,  or  by  other  nervous 
events,  the  lumbar  sphincter  centre  may  be  inhibited,  and  thus  the 
sphincter  itself  relaxed;  or  stimulated,  and  thus  the  sphincter  tightened. 
This  relaxation  is  the  second  of  the  voluntary  elements  in  the  act  of  defe- 
cation. By  these  two  alone  the  contents  of  the  descending  colon  might 
be  pressed  onwards  into  the  rectum  and  out  at  the  anus;  but,  since  the 
sigmoid  flexure  itself  is  subject  to  neither  of  these  influences,  such  a  mode 
of  defecation  would  always  end  in  leaving  it  full;  and  therefore  there  is 
superadded  to  these  two  voluntary  elements  an  entirely  involuntary  in- 
crease in  the  peristaltic  action  of  the  sigmoid  flexure  itself.  The  order 
of  events  is  the  reverse  of  what  we  have  stated.  The  sigmoid  flexure  and 
large  intestine  become  more  and  more  full,  while' stronger  and  stronger 
peristalsis  is  excited  in  their  walls.  By  this  means  the  fseces  are  driven 
against  the  sphincter.  Through  a  voluntary  act,  or  sometimes  at  least 
by  a  simple  reflex  action,  the  lumbar  centre  is  inhibited  and  the  sphincter 
relaxed.  At  the  same  moment  the  contraction  of  the  abdominal  muscles 
causes  firm  pressure  on  the  descending  colon,  and  the  contents  of  the  rec- 
tum are  ejected. 

It  should  be  mentioned  that  the  one  fact  on  which  these  physiological 
views  rest,  viz.,  the  normal  empty  state  of  the  rectum,  is  not  universally 
admitted.  Indeed,  as  Hyrtl  says,  the  rectum  will  be  found  by  any  one 
who  practises  frequent  digital  examination,  in  very  different  states  in 
this  regard  at  different  times  in  the  same  individual.  This  may  or  may 
not  be  entirely  due  to  changes  produced  by  constipation  in  those  exam- 
ined; but  even  he  admits  that  it  is  more  often  found  empty  than  any 
other  part  of  the  canal;  and  the  difficulty  which  an  opposite  view  leads 
to  will  be  seen  at  once  by  the  attempt  of  Bushe  to  explain  the  act  of  de- 
fecation, starting  from  the  point  that  the  faeces  accumulate  slowly  in  the 
rectum,  and  gradually  lose  their  thinner  parts  by  absorption  wiiile  tiierc. 
He  goes  on  to  say  that  they  give  rise  to  no  uneasiness  until  a  considerable 
quantity  is  amassed,  when  a  sensation  is  created  which  demands  their 
expulsion.  This  sensation  is,  he  believes,  not  due  to  the  mere  contact  of 
faecal  matter,  for  the  latter  generally  accumulates  in  largo  quantities 
before  the  sensation  is  felt.  Nor  is  it  duo  to  any  peculiar  acrimony 
which  they  obtain  by  their  stay  in  the  rectum,  for  when  the  faeces  are 
fluid,  this  sensation  is  produced  as  soon  as  they  reach  the  rectum. 
Again,  when  once  the  sensation  is  felt  and  not  attended  to,  it  passes 
away,  and  does  not  return  till  the  next  accustomed  period;  and  the 
longer  it  is  unattended  to,  the  less  likely  is  it  to  return  at  all.  In  truth, 
he  says,  we  are  ignorant  of  the  cause  of  this  feeling,  and  must,  in  the 
present  state  of  our  knowledge,  admit  that  it  is  organic,  and  consequently 
dependent  upon  some  spontaneous  change  in  the  intestine,  of  which  we 
know  nothing.     Rather  a  lame  conclusion!    Nor  is  the  cause  of  this 


28  DISEASES   OF   THE   EECTTJM    AND   ANUS. 

periodically  recurring  desire  to  evacuate  the  bowel  touched  upon  in  the 
exposition  given  by  O'Beime;  and  this  is  the  weak  point  in  his  argu- 
ment, and  the  one  which  renders  Foster's  explanation  complete. 

We  need  cite  authorities  no  further  to  show  that  physiology  no  longer 
teaches  the  existence  of  an  ever-present  mass  of  faeces  in  the  lower  bowel, 
ready  to  escape  at  any  moment  when  the  active  watchfulness  of  the 
sphincter  muscle  is  relaxed,  or  to  prove  that  into  our  present  understand- 
ing of  the  cause  of  the  emptiness  of  the  rectum  a  third  sphincter  muscle 
does  not  enter  as  a  necessary  element,  but  that  the  true  explanation  of 
the  condition  lies  in  the  anatomy  of  the  sigmoid  flexure,  which,  by  its 
large  size,  great  capability  of  expansion,  loose  mesenteric  attachment, 
and  position,  is  peculiarly  fitted  to  act  the  part  of  a  reservoir. 

Nor  does  the  phenomenon  of  retention  of  faeces  after  the  destruction 
of  the  anus  and  its  muscles  necessitate  the  belief  in  a  superior  sphincter. 
So  far  as  our  reading  goes,  no  one  has  as  yet  attempted  to  prove  the  ex- 
istence of  a  fourth  sphincter  in  the  ascending  colon;  and  yet  the  same 
control  over  the  passages  which  has  been  noticed  after  extirpation  of  the 
anus,  and  has  been  supposed  to  indicate  a  third  sphincter,  has  been  ob- 
served to  follow  an  artificial  anus  in  the  transverse  colon. ' 

There  are  several  ways  of  accounting  for  the  slight  control  over  the 
evacuations  which  many  patients  are  found  to  have  after  extirpation  of 
the  anus,  apart  from  the  existence  of  a  third  sphincter  or  of  the  valves 
of  the  rectum.  Indeed,  the  physiology  of  the  act  of  defecation  itself, 
which  we  have  just  described,  goes  far  to  explain  why  there  should  be  a 
certain  warning  of  an  approaching  evacuation,  and  this  is  what  is  gener- 
ally meant  when  the  patients  are  reported  to  have  a  certain  amount  of 
control  over  the  movements.  The  control  will  be  found  in  most  cases  to 
mean  rather  a  consciousness  of  an  approaching  movement,  a  warning 
given  in  sufficient  time  to  allow  the  patient  to  make  necessary  arrange- 
ments, than  an  ability  to  absolutely  prevent  the  evacuation  which  is 
about  to  take  place.  Of  actual  control  there  is  little,  because  the  sphinc- 
ter muscle,  whose  duty  it  is,  under  the  power  of  the  will,  to  prevent  an 
evacuation,  is  absent.  To  the  performance  of  this  duty  a  healthy  sphinc- 
ter is  abundantly  equal,  as  every  one  has  the  chance  to  prove  on  his  own 
person;  and  it  is  this  ability  to  delay  and  postpone  an  evacuation  of  the 
bowels,  rather  than  a  constant  action  in  preventing  the  escape  of  faces 
which  are  ever  ready  to  escape,  which  best  expresses  the  true  function  of 
the  muscle.  After  extirpation  of  the  anus,  this  one  element  of  natural 
defecation  is  destroyed,  but  several  others  are  left.  Th^  faeces  tend  to 
remain  by  their  own  consistence  unless  actively  urged  forward  by  the 

'  The  case  was  that  of  Fine,  of  Geneva,  in  1797.  "  He  formed  an  artificial 
anus,  by  which  the  fjecal  matters  escaped  not  continually,  but  once  or  twice  a  day 
only,  and  with  a  sensation  of  impending  necessity  which  gave  the  patient  time 
to  make  the  slight  preparations  necessary  to  avoid  soiling  herself." — Manuel  de 
Med.  Pratique  "  de  Le  Louis  Odier,  de  Geneve.     2me  ed.,  1811. 


I'KACTICAL   POINTS   IS    ANATOMY    AND    PHY8IOLOOY.  29 

peristalsis  of  the  bowel;  and  this  peristalsis  is  not  constant,  but  recurs 
periodically.  The  relative  increase  in  the  muscular  elements  in  the  rec- 
tum tends  to  keep  it  closed  and  empty  until  faeces  are  forced  into  it  from 
above.  Again,  the  pressure  of  the  faeces,  owing  to  the  S-shaped  form  of 
the  rectum,  is  not  in  the  direction  of  the  axis  of  the  tube,  but  constantly 
against  the  wall,  and  at  the  points  of  greatest  curvature  the  resistance 
is  greatly  increased.  To  these  let  us  add  the  contraction  of  the  cicatrix 
after  extirpation,  and  the  natural  redundancy  of  the  mucous  membrane 
which  may  block  up  the  new  anus  by  an  actual  prolapse,  and  we  have  the 
factors  which  account  for  the  clinical  fact  so  often  seen.  On  the  other 
hand,  the  constant  escape  of  faeces,  which  at  first  almost  always  follows 
these  severe  surgical  operations  upon  the  rectum,  is  best  explained,  by  the 
irritation  of  the  wound  and  the  constant  reflex  action  which  it  excites. 

That  the  folds  of  raucous  membrane,  such  as  have  been  described,  are 
of  the  nature  to  form  an  obstruction  to  the  passage  of  the  faeces,  would 
seem  to  admit  of  no  reasonable  doubt.  But  this  obstruction  is  passive, 
and  not  active,  and  is  by  no  means  sphincteric  in  character.  When  it  is 
suflEiciently  great  to  form  a  real  obstruction  to  the  descent  of  faeces,  the 
condition  is  an  abnormal  one,  but  such  a  condition  is  sometimes  seen, 
and  is  one  which  is  not  to  be  disregarded  in  the  patholog^of  stricture  of 
the  rectum. 

From  a  study  of  the  literature  of  this  question,  and  from  the  results 
of  dissections  and  experiments  which  we  have  personally  been  able  to 
make,  we  are  led  to  the  following  conclusions: 

1.  What  has  been  so  often  and  so  differently  described  as  a  third  or 
superior  sphincter  ani  muscle  is  in  reality  nothing  more  than  a  band  of 
the  circular  muscular  fibres  of  the  rectum. 

2.  This  band  is  not  constant  in  its  situation  or  size,  and  may  be  found 
anywhere  over  an  area  of  three  inches  in  the  upper  part  of  the  rectum. 

3.  The  folds  of  raucous  membrane  (Houston's  valves)  which  have 
been  associated  with  these  bands  of  muscular  tissue,  stand  in  no  necessary 
relation  with  them,  being  also  inconstant,  and  varying  much  in  size  and 
position  in  different  persons. 

4.  There  is  nothing  in  the  physiology  of  the  act  of  defecation,  as  at 
present  understood,  or  in  the  fact  of  a  certain  amount  of  continence  of 
faeces  after  extirpation  of  the  anus,  which  necessitates  the  idea  of  the  ex- 
istence of  a  superior  sphincter. 

5.  When  a  fold  of  mucous  membrane  is  found  which  contains  muscu- 
lar tissue,  and  is  firm  enough  to  act  as  a  barrier  to  the  descent  of  the 
faeces,  the  arrangeraent  may  fairly  be  considered  an  abnormality,  and  is 
very  apt  to  produce  the  usual  signs  of  stricture. 


30  DISEASES    OF   THE    EECTUM    AND    ANUS. 


CHAPTER    II. 

GONCENITAL   MALFORMATIONS   OF   THE    RECTUM   AND   ANUS. 

Separate  Development  of  Rectum  and  Anus. — Narrowing  of  the  Anus  or  Rectum, 
without  Complete  Occlusion. — Congenital  Stricture. — Closure  of  the  Anus  by  a 
Membranous  Diaphragm. — Entire  Absence  of  the  Anus,  the  Rectum  Ending  in 
a  Blind  Pouch  at  a  Point  more  or  Less  Distant  from  the  Perineum, — Rectum 
Same  as  in  Last  Variety  and  the  Anus  Normal. — Anus  Absent  and  Rectum 
Opening  by  an  Abnormal  Anus  at  Some  Point  in  the  Perineal  or  Sacral 
Regions. — Cases. — Anus  Absent  and  Rectum  Ending  in  the  Bladder,  Urethra, 
or  Vagina. — Cases. — Rectum  and  Anus  Normal,  but  Ureters,  Uterus,  or 
Vagina  Empty  into  Rectum. — Total  Absence  of  Rectum. — Absence  of  Large 
Intestine. — Obliteration  from  Intra-Uterine  Disease. — Treatment. — Operation 
Should  Always  be  Performed  and  Without  Delay. — Attempt  Should  First  be 
Made  to  Establish  an  Anus  in  the  Anal  Region. — Measurements  of  Pelvis  at 
Birth. — Use  of  Trocar  not  Justifiable. — Useful  Anus  Seldom  Obtained  by 
Means  of  Incision  Alone. — Objections  to  Cutting  Operation  Without  Plastic 
Operation. — Proctoplasty. — If  Attempt  to  Establish  New  Anus  in  Anal 
Region  Fail,  Colotomy  at  Once  to  be  Performed.— Inguinal  Preferable  to 
Lumbar  Colotomy. — History  of  Colotomy. — Callisen. — Amussat. — Descrip- 
tion of  Operation  of  Colotomy. — Dangers  of  Operation. — The  Inguinal  Oper- 
ation.— Description. — Attempts  at  Establishing  Anus  in  Anal  Region  after 
Colotomy  Generally  Unsuccessful. — Cases. — Closure  of  Artificial  Anus. — 
Operation  of  Dupuytren. — Modifications  of  Dupuytren's  Operation. 

The  study  of  embryology  has  revealed  the  fact  that  the  anus  and  the 
rectum  are  developed  separately.  The  anus  is  at  first  represented  by  a 
simple  depression  in  the  skin  of  the  perineum  which  gradually  extends 
in  depth  and  advances  to  join  the  rectum.  The  rectum  is  developed  in 
connection  with  the  other  abdominal  viscera,  gradually  separates  itself 
from  them,  and  ending  in  a  blind  pouch,  advances  to  meet  the  anal  de- 
pression. At  the  proper  time  the  two  coalesce  and  the  intestinal  canal 
is  complete.  This  process  of  development  of  either  the  rectum  or  anus 
may  be  arrested  at  almost  any  stage  and  the  result  will  be  one  of  the 
various  malformations  which  are  now  to  be  described. 

These  congenital  malformations  have  been  classified  by  different 
writers  into  various  groups.     We  shall  adopt  in  the  following  pages  that 


CONOENITAL   MALFORMATIONS   OF   THE    BBSOTUM    AND    ANUS.  31 

of  Papendorf '  which  is  the  one  followed  by  Bodenhamer,*  MoUiere,*  and 
Esmarch.* 

1.  Narrowing  of  the  Anus  or  Rectum  without  Complete  Occlusion. — 
A  congenital  stricture  of  the  anus,  or  of  the  rectum  at  a  point  more  or 
less  removed  from  the  anus,  has  been  occasionally  reported.  Serremone* 
particularly  insists  upon  congenital  narrowness  of  the  anus  as  a  cause  of 
fissure,  and  has  himself  observed  such  cases;  and  the  same  condition  in 
the  rectum  is  generally  included  among  the  causes  of  benign  stricture. 

The  narrowing  in  these  cases  may  be  very  slight,  or  may  reach  such  a 
degree  as  hardly  to  admit  of  the  passage  of  meconium.  It  is  generally 
annular  in  form,  resembling  the  contraction  which  would  be  caused  by 
tying  a  tape  tightly  around  the  tube.  There  may  be  no  symptoms 
caused  by  such  a  contraction,  and  the  child  may  grow  to  adult  life  suffer- 
ing only  from  obstinate  constipation;  nor  do  such  contractions  lead  to 
the  ordinary  changes  in  the  mucous  mepabrane  above  and  below  the  spot 
which  are  usually  seen  in  cases  of  stricture  of  the  rectum.  On  the  other 
hand,  when  the  stricture  is  tight  it  will  give  rise  to  all  the  usual  signs  of 
such  a  condition  in  the  child — absence  of  free  passage  of  meconium,  dis- 
tention of  the  abdomen,  and  vomiting.  The  diagnosis  is  easily  made  by 
a  digital  examination  should  the  symptoms  be  sufficiently  marked  to  lead 
the  attention  of  the  surgeon  to  the  rectum;  for  the  stricture  is  generally 
near  the  anus  and  may  be  felt  as  a  ring  with  sharp  edges.  The  treat- 
ment consists  either  in  dilatation  or  in  nicking.* 

2.  Closure  of  the  Anus  ly  a  Membranous  Diaphragm. — The  mem- 
brane in  these  cases  may  be  of  greater  or  less  firmness  and  thickness,  and 
may  be  composed  of  skin  or  of  mucous  membrane.  It  is  sometimes  so 
thin  as  to  bulge  out  with  meconium  when  the  child  strains  or  coughs, 
and  has  been  known  to  rupture  spontaneously. 

This  is  the  simplest  of  all  the  forms  of  congenital  malformation  of 
the  anus,  and,  unfortunately,  one  of  the  rarest.  It  is  easily  diagnosti- 
cated by  simple  inspection  of  the  parts;  and  the  treatment  consists  m 
making  a  crucial  incision  through  the  membrane.     The  remains  of  the 


'  "  Dissertatio  sistens  observationes  de  ano  infantum  imperforate."  Lugd. 
Batav.,  1781,  4to.  (Bodenhamer). 

"  "  A  Practical  Treatise  on  the  Etiology,  Pathology,  and  Treatment  of  the  Con- 
genital Malformations  of  the  Rectum  and  Anus."  by  Wm.  Bodenhamer,  New- 
York.    AVm.  Wood  &  Co.,  1860. 

'  "Traite  des  ^laladies  du  rectum  et  de  Tanus,"  par  Daniel  Molliere.  Paris, 
1877. 

*  Op.  cit. 

*  Inaugural  Thesis.    Strasbourg,  1861,  No.  555. 

*  See  also  Gosselin,  "  Clinique  Chirurg.,"  3d  ed.  Paris,  1879,  T.  iii.,  p.  706. 
Berard  et  Maslieurat-Lagemar,  Gaz.  Med.  de  Paris,  1839,  p.  146.  Demarquay, 
Journal  de  I'experience,  t.  ix.,  1843,  p.  273.  Ashton,  "Diseases  of  the  Rectum," 
London.  1854,  p.  27.     Devilliers,  Rev.  Med.  de  Paris,  1835. 


32 


DISEASES    OF    THE    KECTUM    AND    ANUS. 


membrane,  like  those  of  the  hymen  which  it  strongly  resembles,  will 
shrink  up  so  as  not  to  cause  trouble  or  deformity. 

3.  Entire  Absence  of  the  Anus,  the  Rectum  ending  in  a  Blind  Pouch 
at  a  Point  more  or  less  Distant  from  the  Periiieuni. 

In  these  cases  there  may  be  a  slight  depression  at  the  point  where  the 
anus  should  be  found;  or  there  may  be  no  trace  of  the  anal  orifice;  the 
raphe  of  the  perineum  extending  over  the  spot  and  back  to  the  coccyx. 
The  external  sphincter  muscle  is  also  sometimes  present  and  at  others 
entirely  wanting.  The  pouch  of  the  rectum  in  these  cases  may  hang 
loose  in  the  pelvis  or  abdominal  cavity,  or  be  attached  to  some  adjacent 
pai't;  and  the  space  between  it  and  the  perineum  may  be  filled  up  with 


Fig.  7.— <Molli6re). 

cellular  tissue,  or  in  other  cases  a  distinct  fibrous  cord  may  be  traced 
from  the  rectal  pouch  to  the  skin,  as  is  shown  in  the  plate. 

If  the  pouch  of  the  rectum  be  not  at  too  great  a  distance  from  the 
skin,  a  sense  of  fluctuation  may  be  felt  by  firm  pressure  with  one  finger 
over  the  anus  and  the  other  hand  on  the  abdomen.  In  females,  valuable 
aid  in  diagnosis  may  be  obtained  by  the  introduction  of  a  finger  into  the 
vagina.  The  use  of  a  stethoscope  over  the  anus,  and  of  percussion  on  the 
abdomen,  has  been  recommended  to  detect  the  rectal  pouch  filled  with  gas 
(Bodenhamer,  MoDiere);  and  also  the  irritation  of  the  skin  over  the  anus 
to  provoke  efforts  at  defecation. '  An  efEort  should  always  be  made,  where 
there  is  complete  absence  of  the  anus,  to  discover  whether  the  rectum 


'  A.   Copeland  Hutchinson: 

1826. 


Practical  Observations  in  Surgery,"  London, 


CONGENITAL.    MALFORMATIONS   OF   THE    KEOTL'M    AND    AN 08. 


33 


may  not  have  some  outlet  through  the  bladder  or  vagina,  which  shall 
place  the  case  in  one  of  the  classes  soon  to  be  described. 

4.  The  rectum  may  he  the  same  as  in  the  last  variety,  and  the  anus 
be  normal. 

The  septum  which  separates  the  rectal  and  anal  poaches  in  this  case 
is  generally  within  easy  reach  of  the  anus,  and  may  be  so  thin  as  to  per- 
mit a  sense  of  fluctuation.  In  most  cases,  however,  the  septum  is 
thicker,  and  is  composed  of  cellular  or  fibrous  tissue,  lined  both  above 
and  below  by  mucous  membrane.     It  may  be  perforated,  like  the  hymen, 


Fio.  6.— (MoUK-re). 

at  some  point,  and  allow  of  the  slow  dribbling  of  meconium.  There  may 
also  be  more  than  one  septum.  Voillemier'  reports  one  case  in  which 
the  rectum  was  divided  in  this  way  into  four  distinct  compartments,  the 
upper  one  containing  meconium,  and  the  others  mucus.  There  is  gen- 
erally little  difficulty  in  the  diagnosis  of  these  cases,  provided  only  a 
digital  examination  be  made  when  the  infant  begins  to  show  the  effects 
of  the  obstruction;  but  the  danger  lies  in  the  fact  •of  the  normal  anus, 
which  is  apt  to  allay  suspicion  as  to  the  true  nature  of  the  difficulty.' 


»  Gaz.  des  Hop..  1846. 

*  ••  Dr.  H,  G.  Jameson,  of  Baltimore  (Medical  Recorder,  vol.  v.,  1822,  p.  290), 
divided  two  membranous  septa,  one  above  the  other,  with  a  button-headed 
bistoury,  which  he  passed  '  into  the  opening  or  ring  of  the  septum,'  and  cut  freely 
down  toward  the  sacrum.  This  was  done  inSeptember.  1821 .  The  patient  got  well. 
Roser  (Arch.  fOr  Physiol.  Heilkunde,  1859.  p.  125)  mentions  a  circular  valvular 
stricture  an  inch  from  the  anus  m  a  little  girl  of  four,  which  he  treated  by 
division."  Van  Buren,  "  Lectures  upon  Diseases  of  the  Rectum  and  the  Surgery 
of  the  Lower  Bowel."  New  York:  D.  Appletou  &  Ck).,  1881,  p.  263,  note. 
3 


34 


DISEASES   OF    THE    RECTUM   AND    ANUS. 


5.  Tlie  anus  may  he  absent,  and  the  rectum  may  open  by  an  abnormal 
amis  at  any  point  in  the  perineal  or  sacral  regions. 

When  the  rectum  terminates  in  the  glans  penis,  the  labia,  or  at 
some  abnormal  point  in  the  perineum,  the  lower  portion  of  it  is  usually 
of  a  fistulous  character,  as  shown  in  the  plate,  but  lined  by  true  mucous 
membrane;  and  the  anus,  whether  in  the  perineum  or  at  the  base  of  the 
sacrum,  or  tip  of  the  coccyx,  is  always  narrow  and  insufficient  for  its 
purpose.  A  modification  of  this  class  of  abnormalities  is  found  in  those 
cases  where  the  rectum  terminates  in  two  openings  at  a  greater  or  less 
distance  from  each  other. 


Fig.  9.— (Molliere). 

Cruveilhier'  reports  a  case  of  this  nature,  in  which  the  fistulous  pro- 
longation of  the  rectum  ran  subcutaneously  in  the  scrotal  raphe,  and 
terminated  at  the  glans  penis. 

Mr.  Morgan''  has  recently  reported  two  modifiations  of  this  species  of 
deformity  which  are  rarely  met  with,  and  are  easily  relieved.  In  the 
first,  the  anus  was  of  the  usual  size  a;id  in  the  proper  location ;  but  there 
was  found  to  be  a  band  of  tissue  passing  from  a  point  corresponding  to 
the  apex  of  the  coccyx  to  the  median  raphe  of  the  scrotum,  with  the 
posterior  extremity  of  which  it  was  continuous.  The  band  was  about 
three-quarters  of  an  inch  long,  and  was  attached  at  both  ends,  the  re- 
mainder forming  a  thick,  free  cord,  which  lay  below  the  aperture  of  the 
anus,  while  from  the  centre  of  this  band  there  ran  a  small  branch  of 
similar  tissue,  which  was  attached  to  the  skin  of  the  left  buttock,  and 
was  about  half  an  inch  in  lenorth.   'The  skin  covenns:  the  central  bund 


'  Anat.  Pathologique  du  Corps  Humain,  t.  i.,  Liv.  i.,  Planche  vi. 

*  Three  Cases  of  Unusual  Deformity  of  the  Anus.  Lancet,  October  2  2d.  13SI. 


CONGENITAL    MALI-ORMATIOXS    OF   THE    RECTUM    AND    ANUS. 


35 


exactly  resembled  that  of  the  scrotum,  shrinking  and  contracting  upon 
stimulation,  and  it  was  so  placed  that  any  passage  of  faeces  must  cause 
it  to  be  stretched,  thus  accounting  for  the  pain  attending  each  motion 
of  the  bowels. 

The  second  case  was  similar.  The  child  was  borA  with  an  imper- 
forate anus,  but  the  membranous  septum  gave  way  spontaneously.  The 
child,  however,  continued  to  suffer  pain  on  defecation,  and  on  examina- 
tion, there  was  seen  a  small,  thick  band  passing  from  the  median  raphe 
of  the  perineum  in  front  to  the  depression  between  the  buttocks  posteri- 
orly, and  broadest  behind.  At  a  spot  corresponding  to  the  anus,  on  either 
side  of  the  band,  was  a  depression;  that  on  the  right  was  patent,  and 
allowed  a  probe  to  pass  into  the  anus;  that  on  the  left,  though  similar  in 
appearance,  proved  to  be  only  a  cul-de-sac. 


Fio.  10.-(MoU16re). 


In  a  third  case,  there  was  a  depression  at  the  usual  site  of  the  anus, 
and  the  parts  around  were  so  far  natural  that  the  skin  wjis  pigmented 
and  puckered,  but  there  was  no  communication  with  the  rectum.  The 
spot  at  which  the  faeces  passed  was  in  the  median  line  half-way  between  this 
depression  and  the  posterior  commissure,  but  nearer  the  latter  than  the 
former.  The  opening  was  very  small,  and  a  probe  passed  up  into  it, 
showed  an  abundance  of  tissue  between  the  passage  and  the  vagina. 
The  cure  consisted  in  enlarging  this  abnormal  opening  posteriorly  into 
the  depression  representing  the  natural  one.  Delans'  reports  an  anal- 
ogous case  in  a  well-nourished  child  aged  four  and  a  half  years.  There 
were  two  openings,  one  on  each  side  of  a  median  bridle,  which  was  con- 

'  See.  de  Chirurgie,  March  24th,  1875. 


36  DISEASES    OF   THE    KECTDM    AND    ANUS. 

tinuous  with  the  raphe  in  front  and  behind,  and  was  composed  only  of 
skin  and  mucous  membrane.  Each  opening  seemed  to  be  the  natural 
one,  but  the  one  on  the  left  was  a  cul-de-sac  fifteen  millimetres  deep. 
The  septum  was  excised,  with  what  result  is  not  stated. 

6.  The  anus  may  he  absetit  and  the  rectum  may  end  in  the  bladder, 
'urethra,  or  vagina. 

Of  these  varieties  that  in  which  the  rectum  opens  into  the  vagina  is 
the  most  common.  In  females  the  opening  is  seldom,  if  ever,  into  the 
bladder,  but  sometimes  it  is  into  the  urethra.  In  males  it  is  more  often 
into  the  bladder  than  into  the  urethra,  and  in  such  cases  the  rectum  may 
terminate  either  by  a  narrow  duct  running  obliquely  through  the  bladder 
and  opening  in  the  has-fond  between  the  orifices  of  the  ureters,  or  by  a 
free  opening.  The  symptoms  of  this  condition  will  of  course  vary  greatly 
according  to  the  location  of  the  abnormal  opening.  "When  the  commu- 
nication is  between  the  rectum  and  bladder  the  fact  will  be  shown  by  the 
mixture  of  the  meconium  with  the  urine,  rendering  the  latter  thick  and 
greenish  in  color.  The  amount  of  meconium  present  will  also  indicate 
whether  the  opening  is  large  or  small.  This  condition  is  generally  fatal 
from  the  development  of  cystitis,  and  from  intestinal  obstruction  unless 
the  condition  be  relieved  by  the  appropriate  surgical  interference.' 

"When  the  communication  is  urethral  in  the  male,  the  meconium  will 
often  escape  independently  of  the  act  of  urination.  The  prognosis  is  not 
us  bad  in  these  cases  as  in  the  vesical  variety;  several  being  recorded  in 
v.hich  life  has  been  preserved  for  a  number  of  years.  Gross"  relates  one 
case  in  a  man  aged  thirty;  and  Bodenhamer  cites  several  others  in  which 
children  have  lived  three  or  four  years. 

In  the  female  the  prognosis  is  more  favorable  than  in  the  male,  from 
the  greater  facility  with  which  the  meconium  escapes. 

Where  the  abnormal  opening  is  between  the  vagina  and  rectum,  and  is 
of  considerable  size,  as  it  generally  is,  the  prognosis  is  not  necessarily 
grave.  Women  have  been  known  to  live  to  a  good  old  age,  even  to  reach 
one  hundred  years  in  the  case  of  Morgagni,  with  this  malformation,  and 
to  perform  all  the  duties  of  wives  and  mothers  without  even  being  con- 
scious of  anything  abnormal  (Fournier,'  Kicord). 

7.  TJie  rectum  and  anus  are  tiormal,  hut  the  ureters,  uterus,  or  vagina 
empty  into  the  rectal  cavity  and  discharge  their  coyitents  through  it. 
This  species  of  malformation  is  rare  and  is  usually  attended  by  other  signs 


1  As  showing  what  the  bladder  and  urethra  may  bear,  however,  Rowau's  case 
is  of  great  interest.  In  it  defecation  took  place  through  the  penis  for  two  months 
without  causing  any  signs  of  irritation,  though  the  child  was  several  months  old, 
and  the  rectum  was  filled  with  well-formed  hard  faeces.  Australian  Med.  Journal, 
Mar.,  1877. 

« A  System  of  Surgery.     Phila..  H.  C.  Lea,  1872,  vol.  ii.,  p.  657. 
.  3 Diet,  des  Sci.  Med.,  t.  iv.,  p.  155 


CONOEMITAL   MALF0KMATI0N8    OF   THE    RECTUM    AND    AND8.  37 

of  imperfect  development.    It  is  not  incompatible  with  life  or  with  con- 
ception. 

8.  Total  absence  of  the  rectum.  This  variety  differs  only  from  the 
third  in  the  amount  of  the  rectum  which  may  be  absent.  It  may  or  may 
not  be  attended  by  an  absence  of  the  anus,  but  is  usualjy  only  one  of  the 
signs  of  arrested  development.  The  blind  pouch  of  the  rectum  may 
hang  loose  in  the  abdomen  or  pelvis;  may  be  attached  in  the  base  of  the 
sacrum,  or  to  some  of  the  adjacent  parts;  or  may  be  continued  down  as  a 
fibrous  cord  to  the  site  of  the  anus. 

9.  Absence  of  the  large  intestine.  This  is  also  attended  by  an  absence 
of  the  normal  anus,  the  place  of  which  is  supplied  by  an  abnormal 
opening  in  the  umbilicus,  or  at  some  remote  part  of  the  body,  as,  for  ex- 
ample, the  side  of  the  chest,  or  the  face.  With  this  abnormal  opening  the 
small  intestine  or  what  remains  of  the  colon  communicates. 

Thus  far  only  arrests  or  excesses  of  development  have  been  mentioned. 
The  rectum  and  anus  are,  however,  liable  to  certain  diseases  during  foetal 
life  which  may  result  in  narrowing  or  completely  obliterating  their  cali- 
bre.    Among  these  are  enteritis  and  proctitis.    ' 

Treatment. — The  treatment  of  the  class  of  congenital  contractions  of 
the  anus  and  rectum,  and  of  the  class  of  membranous  septa,  has  already 
been  referred  to,  and  is  exceedingly  simple  and  generally  attended  by 
good  results.  The  treatment  of  the  remaining  varieties,  except  the 
eighth  and  ninth  which  do  not  admit  of  surgical  interference,  may  be 
guided  by  the  following  general  propositions. 

1.  An  operation  should  always  be  performed  and  performed  without 
delay.  There  is  little  to  be  gained  even  by  waiting  for  the  rectal  pouch 
to  become  distended  with  meconium,  and  there  is  much  to  be  lost.  If 
the  obstruction  be  complete,  death  is  a  necessary  result;  being  produced 
by  peritonitis,  by  rupture  of  the  over-distended  bowel,  or  by  a  gradual 
wasting  without  acute  symptoms.  Even  in  cases  where  a  certain  amount 
of  mecopium  makes  its  escape  by  a  narrow  orifice,  and  delay  is  not, 
therefore,  as  necessarily  dangerous  as  in  cases  of  complete  obstruction, 
nothing  is  to  be  gained  by  delay,  and  an  immediate  operation  may  avoid 
a  paralysis  of  the  bowel  from  over-distention. ' 

'  Cripps  (Lancet,  May  15th,  1880)  has  reported  a  most  remarkable  case  bearing 
up)on  this  point.  The  condition  of  imperforate  rectum  was  diagnosticated  on  the 
third  day,  but  operation  was  refused  and  the  child  taken  from  the  hospital. 
Thirty  days  later  she  was  brought  back  again  apparently  quite  well;  the  abdomen 
was  di8tende<i;  food  was  taken  well;  but  three  or  four  times  every  day  she  vom- 
ited faical  matter.  In  this  case,  the  anus  terminated  in  a  blind  pouch  and  a  tro- 
car was  plunged  upwards  through  it.  Only  a  little  serous  fluid  escaped  from  the 
peritoneal  cavity,  and  the  child  died  of  peritonitis.  At  the  autopsy,  the  rectal 
cul-de-sac  was  found  just  above  the  anal  |X)uch,  but  the  trocar  had  penetrated  the 
peritoneal  pouch  between  the  two.  There  are  two  noteworthy  points  in  the  case. 
The  first  is  the  remarkable  manner  in  which  nature  accommodated  itself  to  ihe 
deformity;  and  the  second  is  the  ease  witli  which  the  rectal  pouch  may  be  missed 
with  a  trocar. 


38  DISEASES    OF   THE    EECTL'M    AND    ANUS. 

2.  If  there  he  any  chance  of  establishing  an  opening  at  the  normal  site 
of  the  anus,  the  surgeon  should  at  first  direct  his  attention  to  this  pro- 
cedure. And,  since  in  most  cases  it  is  impossible  to  tell  that  the  rectal 
pouch  may  not  be  within  easy  reach  from  the  perineum,  it  is  generally 
good  surgery  to  make  a  tentative  incision  at  this  point. 

Before  attempting  any  operation  on  a  child's  pelvis,  the  surgeon  should 
remember  the  exceeding  smallness  of  the  space  in  which  he  is  obliged  to 
^ork,  even  in  its  natural  state;  and  also  that  the  normal  measurements 
may  be  decreased  in  any  case  of  congenital  malformation.  These  normal 
measurements,  according  to  Bodenhamer  who  made  them  on  two  new- 
born, well-developed,  male  infants,  at  full  term  are  as  follows : 

1.  !From  one  tuberosity  of  the  ischium  to  the  other,  one  inch  and  one 
line.  From  the  os  coccygis  to  the  symphysis  pubis,  one  inch  and  three 
lines.  From  the  os  coccygis  to  the  promontory  of  the  sacrum,  one  inch 
and  two  lines. 

2.  From  one  tuberosity  of  the  ischium  to  the  other,  one  inch.  From 
the  OS  coccygis  to  the  symphysis  pubis,  one  inch  and  one  and  a  half  lines. 
From  the  os  coccygis  to*  the  promontory  of  the  sacrum,  one  inch  and  one 
line. 

The  means  at  the  disposal  of  the  operator  for  reaching  the  rectal 
pouch  through  the  perineum  and  establishing  a  new  outlet,  consist  in 
puncture,  incision  (proctotomy),  and  in  the  formation  of  a  new  anus  by 
a  plastic  operation  (proctoplasty).  The  operation  by  puncture  consists 
in  plunging  a  trocar  through  the  perineum  in  the  supposed  direction  of 
the  rectum,  for  the  purpose  of  establishing  an  outlet.  It  may  be  done 
without  a  preliminary  incision,  or  after  a  careful  dissection  which  has 
failed  to  reach  the  desired  point. 

3.  The  use  of  a  trocar  as  an  aid  in  finding  the  rectal  pouch  before  or 
after  incisions  through  the  perineum,  is  not  sanctioned  by  modern  surgi- 
cal authority.  It  is  a  procedure  attended  with  the  greatest  danger  to 
the  life  of  the  patient,  and  when  the  rectal  pouch  is  successfully  reached, 
which  is  rare,  the  outlet  thus  made  is  of  little  use.  The  peritoneum, 
bladder,  or  uterus  may  each  be  wounded  by  the  instrument  with  a  fatal 
result;  the  opening  made  is  not  free  enough  to  allow  of  easy  escape  of 
meconium;  nor  can  such  an  opening  be  made  to  serve  the  purpose  of 
rectum  and  anus  by  any  subsequent  dilatation. 

4.  Tlie  results  of  attempts  to  establish  an  outlet  for  an  imperfect  rec- 
tum by  means  of  incisions  alone  through  the  jierineum  are  not  favorable 
as  regards  the  production  of  a  useful  anus. 

The  operation  consists  in  cutting  through  the  perineal  tissues,  stroke 
by  stroke,  until  the  rectal  pouch  is  reached  and  opened.  The  incision 
should  be  longitudinal,  and  should  reach  from  the  scrotum  to  the  tip  of 
the  coccyx.  Should  the  fibres  of  the  external  sphincter  be  encountered 
beneath  the  skin,  they  may  be  carefully  separated  as  near  the  median  line 
as  possible  and  drawn  to  each  side.     The  direction  of  the  dissection, 


CONGENITAL   MALFORMA.TION8    OF   THK    RECTUM    AND    ANUS.  39 

•which  it  is  needless  to  say  should  be  made  with  the  utmost  care,  should 
be  backwards  towards  the  concavity  of  the  sacrum  iu  the  line  which  tht 
rectum  normally  follows.  Additional  safety  may  be  secured  by  th€ 
introduction  of  a  sound  into  the  male  bladder  or  the  female  vagina. 
The  finger  is  to  be  frequently  used  as  a  director  m  exploring  for  the 
rectal  pouch,  while  the  hand  of  an  assistant  makes  pressure  on  the  abdo- 
men. In  this  way  the  dissection  may  be  carried  to  the  depth  of  an  inch 
or  possibly  an  inch  and  a  half,  but  at  this  point,  if  unsuccessful,  it 
should  be  abandoned  for  fear  of  wounding  the  peritoneum. 

This  operation,  though  it  may  be  successful  in  allowing  the  escape  of 
meconium,  and  in  prolonging  life,  does  not,  in  most  cases,  result  in  a 
useful  anus  for  any  great  number  of  years.  This  is  the  experience  of  the 
greater  number  of  writers  upon  this  subject.  Van  Buren'  says:  "  I  have^ 
in  several  instances,  succeeded,  by  careful  dissection,  in  reaching  a  fluc- 
tuating point  of  a  blind  rectal  pouch,  and  in  establishing  a  free  outlet 
for  the  meconium,  but  in  no  case  has  it  proved  permanently  useful.  It 
has  always  been  necessary  to  employ  bougies  or  tents  more  or  less  con- 
stantly to  keep  the  new  canal  from  contracting,  and  the  care,  and  pain, 
and  trouble  of  fighting  against  the  closing  stricture,  and  the  persistent 
tendency  to  obstruction  and  fsecal  accumulation,  have  invariably  led  to 
early  death.  At  present,  I  know  of  no  such  case  treated  in  this  way,  in 
which  a  permanently  satisfactory  result  has  been  attained."  Amussat,* 
Sir  Benjamin  Brodie,  Velpeau,*  Benjamin  Bell,*  and  many  others,  have 
borne  testimony  to  the  same  effect.  On  the  other  hand,  cases  are  occa- 
sionally seen  where  the  result  is  more  favorable,  but  they  constitute  a 
small  minority  of  the  whole.  What  the  operation  really  accomplishes  is 
the  formation  of  a  faecal  fistula,  with  all  the  discomforts  attendant  upon 
such  a  condition. 

It  was  this  difficulty,  combined  with  the  loss  of  two  cases  in  which 
the  operation  had  been  performed  from  blood  poisoning  with  jaundice, 
which  Amussat  considered  to  be  due  to  thQ  absorption  of  meconium  and 
fsecal  matter  by  the  freshly-cut  surface,  which  led  him  to  abandon  this 
operation,  and  to  substitute  in  its  place  the  one  now  to  be  described. 

Operation  of  Atnmnssaf.  Proctoplasty. — This  operation  is  the  same 
as  the  last,  with  the  addition  of  two  important  features.  In  the  first 
place,  the  rectum  is  drawn  down  and  stitched  to  the  skin  ;  and,  second, 
to  facilitate  this,  when  necessary,  the  new  anus  is  made  either  just  at 
the  tij>  of  the  coccyx,  or  that  bone  is  exsected,  and  the  anus  made  in 
the  place  it  occupied.  "Where  much  of  the  lower  end  of  the  rectum  is 
deficient,  it  may  not  be  possible  to  draw  the  cul-de-sac  down  to  the  skin 

»0p.  cit.,  p.  871. 

'  "  Observation  sur  une  Operation  d*Anus  artiflciel,"  etc.    Gkiz.  Med.  de  Paris, 
Nov.  2.Sth,  1835,  p.  753. 

•  "  Nouveau  Elements  de  Meti.  Operatoire."  Paris,  1832. 

*  "  A  System  of  Surgery."  Vol.  ii.,  chapt.  xix.    Edinburgh,  1778. 


40  DISEASES    OF    THE    RECTUM    AND    ANUS. 

without  more  traction  and  dissection  than  it  is  safe  to  employ.  In  such 
cases,  the  excision  of  the  coccyx,  as  originally  recomended  and  practised 
by  Amussat,'  and  more  recently  by  Verneuil,'  besides  adding  to  the  chances 
of  finding  the  rectal  pouch,  diminishes  the  distance  over  which  the  rec- 
tum must  be  stretched.  Unfortunately,  in  the  cases  where  the  opera- 
tion is  most  needed — those  in  which  the  rectal  pouch  is  furthest  from 
the  skin — the  operation  is  not  always  practicable;  and  in  other  cases,  the 
adhesions  of  the  rectum  to  the  bladder  or  vagina  may  be  an  insuper- 
able obstacle.  In  the  latter  class  of  cases,  however,  a  new  anus  may 
be  formed,  and,  if  successful,  the  recto- vaginal  fistula  may  be  closed  by 
subsequent  operations. 

5.  In  case  of  failure  to  establish  a  new  anus  in  the  anal  region,  colo- 
tomy  should  at  once  be  performed. 

The  teachings  of  different  authorities  will  vary  as  to  the  propriety  of 
first  performing  the  perineal  operation  before  resorting  to  colotomy,  ac- 
cording to  the  views  of  each  one  upon  the  question  of  the  desirability  of 
colotomy.  Some  follow  the  rule  I  have  laid  down,  that  it  is  always  bet- 
ter to  attempt  the  perineal  operation  where  there  is  a  chance  of  its  suc- 
ceeding ;  others  limit  the  latter  operation  to  cases  where  the  rectal  pouch 
is  known  to  be  near  the  skin,  and  in  all  others  turn  their  efforts  at  once 
toward  the  colon.  The  abdominal  operation  is  obviously  the  only  one 
where  the  rectum  ends  high  up  in  the  pelvis,  and  it  is  generally  to  be 
preferred  in  that  class  of  cases  where  it  opens  into  the  bladder  or  urethra. 

6.  In  the  formation  of  an  artificial  anus,  the  left  groin  is  the  best  site 
for  the  operation. 

The  colon  may  be  opened  either  in  the  loin  or  groin,  and  on  either 
the  left  or  right  side.  There  is  some  uncertainty  in  the  early  history  of 
colotomy  and  some  ambiguity  of  terms,  which  is  apt  to  mislead.  The 
idea  of  an  artificial  anus  was  first  proposed  by  Littre,"  in  1710,  and  the 
incision  he  recommended  was  simply  "  aii  ventre  "  (in  the  abdomen) ;  the 
design  being  to  reach  the  sigmoid  flexure.  He  never  practised  the 
operation  which  at  present  passes  under  his  name — that  of  opening  tlie 
bowel  in  the  groin,  nor  did  the  operation  he  proposed  involve  the  idea  of 
preserving  the  peritoneum  intact. 

About  the  year  1770,  Pillore,  of  Eouen,  actually  performed  the  first 
operation  of  this  nature,  by  making  an  opening  into  the  caecum,  in  a 
case  of  cancer  of  the  rectum  which  caused  complete  obstruction.  The 
patient  survived  twenty-eight  days,  and  death  was  not  due  to  the  opera- 
tion. In  1783,  Dubois  operated  in  the  same  way  for  imperforate  anus, 
but  the  operation  was  unsuccessful,  and  the  child  died  on  the  tenth  day. 

'  Troisieme  Memoire  sur  la  rossibilite  d'etablir  une  ouverture  artificielle  sur 
la  coion  lombaire  gauche  sans  ouvrir  la  Peritoine,  cliez  les  enfans  imperfores. 
Paris,  1842. 

*  Gaz.  des  Hop.  de  Paris,  July  29th,  Aug.  5th,  1873,  pp.  604,  715. 

^  Histoire  de  L'Acad.  Roy.  des  Sci.  de  Paris,  1710,  p.  86. 


OONOENITAL    MALFORMATIONS    OF   THE    KECTUM    AND    AND8.  41 

In  1793,  Duret,  of  Brest,  opened  the  sigmoid  flexure  of  a  child  two 
days  old,  and  this  child  lived  to  adult  age.  In  1794,  Desault  practised 
the  same  operation  without  success,  and  in  1797,  Fine,  of  Geneva,  made 
an  artificial  anna  in  the  arch  of  the  colon  for  cancer  of  the  upper  part  of 
the  rectum,  which  was  also  successful,  the  woman  living  three  months 
and  a  half. '  In  1814,  the  operation  was  successfully  performed  for  cancer 
of  the  rectum  by  Martland  ;*  in  1817,  by  Freer,  of  Birmingham;*  and  in 
1820,  by  Pring.*  In  many  of  these  cases  the  original  operation  of  Littre 
was  modified  to  suit  the  operator ;  but  in  none  of  them  was  any  attention 
paid  to  wounding  the  peritoneum. 

An  undue  prominence  seems  to  attach  to  the  name  of  Callisen  in 
connection  with  the  operation  in  the  left  loin.  There  was  nothing  origi- 
nal in  his  choice  of  location,  nor  did  he  bring  out  the  idea  of  operating 
without  wounding  the  peritoneum.  He  believed  that  the  intestine  could 
be  more  easily  reached  from  this  point  than  any  other,  in  which  he  cer- 
tainly was  in  error;  and  on  the  whole  he  condemned  the  operation  in  the 
following  words;*  **The  incision  of  the  caecum  and  descending  colon, 
which  has  been  proposed,  in  this  state  of  things  (imperforate  rectum)  by 
means  of  an  incision  in  the  left  lumbar  region  at  the  border  of  the  qua- 
dratus  lumborum,  to  establish  an  artificial  anus,  presents  a  very  uncertain 
chance,  and  the  life  of  the  little  patient  can  scarcely  be  saved;  neverthe- 
less, the  intestine  may  be  reached  more  easily  in  this  place  than  above  in 
the  iliac  region." 

It  is  in  reality  to  Amussat  that  the  extra-peritoneal  operation  in  the 
loin  IS  due,  and  the  operation  which  he  described*  is  the  one  now  in  favor 
and  the  one  usually  spoken  of  as  that  of  Callisen. 

The  guide  to  the  descending  colon  is  the  outer  border  of  the  quadratus 
lumborum  muscle;  and  the  guide  to  the  outer  border  of  the  muscle  is  a 
perpendicular  from  a  point  one-half  inch  posterior  to  the  middle  of  the 
crest  of  the  ilium;  or  to  a  point  half  an  inch  posterior  to  the  middle  of  a 
line  drawn  from  the  anterior  superior  to  the  posterior  superior  spinous 
process.  This  point  should  first  of  all  bo  accurately  determined  and 
marked  with  ink  or  iodine,  for  the  edge  of  the  muscle  cannot  easily  be 
felt  in  many  subjects.  The  descending  colon  is  here  in  great  part 
uncovered  by  peritoneum,  being  behind  that  membrane  and  in  immedi- 
ate contact  with  the  transversalis  fascia.     The  patient  should  be  placed 

'  "Manuel  de  med.  prat,  de  Louis  Adier  de  Geneve."  2<1  Edit.,  1811.  Quoted 
by  Carcopino,  These,  No.  197, 1879.  Parallel  entre  Textirpation  du  rectum  et  I'eta- 
blissement  de  Tanus  artificiel. 

•Edinburgh  Med.  and  Surg.  Jour.,  Oct.  1823,  p.  271. 

•  Carcopino.    These. 

♦London  Med.  and  Physical  Journal,  1821. 

* "  Systema  Chirurgiae  hodiemae."  t.  i..  Haffiniae,  1813. 

•  "  Quelques  reflexions  pratiques  sur  les  retrecissements  du  rectnm."  Gaz. 
Med.  de  Paris,  1839,  No.  1. 


42  DISEASES    OF    THE    RECTUM    AND    ANUS. 

upon  a  hard  pillow  so  that  the  loin  may  be  brought  into  prominence,  and 
the  operator  should  stand  at  the  back  of  the  patient. 

The  incision  should  cross  the  edge  of  the  quadratus  obliquely  from 
above  downwards  and  from  behind  forwards,  beginning  at  the  left  of  the 
spine  below  the  last  rib,  and  extending  four  or  five  inches.  In  this  way 
the  middle  of  the  outer  border  of  the  muscle  will  correspond  to  the  middle 
of  the  incision,  and  the  large  branches  of  the  spinal  nerves  will  not  be 
severed.  The  incision  is  then  carried  carefully  down,  layer  by  layer, 
through  the  latissimus  dorsi,  external  and  internal  oblique,  and  transversa- 
lis  muscles,  till  the  outer  border  of  the  quadratus  is  recognized;  care  being 
taken  that  as  the  incision  grows  deeper  it  does  not  also  grow  shorter, 
till  when  the  bowel  is  reached  the  operator  finds  himself  working  in  the 
small  end  of  the  funnel.  If  possible  the  outer  border  of  the  quadratus 
should  be  distinctly  recognized  before  the  transversalis  fascia  is  divided, 
under  which  lies  the  colon  moiie  or  less  enveloped  in  fat.  "When  dis- 
tended either  artificially  by  air,  or  by  the  faeces,  it  is  recognized  either  by 
the  feel  of  the  faeces  or  by  its  longitudinal  muscular  bands.  When,  on 
the  other  hand,  it  is  collaj^sed  (and  Molliere'  has  called  attention  to  the 
fact  that  it  may  be  collapsed  even  in  cases  of  prolonged  retention,  the 
accumulation  being  either  above  or  below  the  point  of  operation),  the 
patient  may  be  turned  on  the  back  to  allow  it  to  fall  into  the  wound,  or 
pressure  may  be  made  on  the  abdomen  by  an  assistant.  Bryant  recom- 
mends rolling  the  bowel  partially  forward  after  it  has  been  seized,  to 
bring  its  posterior  surface  into  the  wound,  as  an  additional  safeguard 
against  wounding  the  peritoneum. 

When  the  bowel  has  been  drawn  well  out  to  the  surface  of  the  wound, 
it  must  be  secured  in  position  before  it  is  opened,  in  order  that  its  con- 
tents may  not  escape  into  the  abdominal  cavity.  This  is  best  done  by 
passing  a  couple  of  ligatures  through  it  and  the  lips  of  the  wound  in  the 
following  manner.  The  needle  is  entered  on  one  side  of  the  incision  and 
carried  through  the  integument  alone,  and  not  through  the  whole  thick- 
ness of  the  adominal  wall,  for  the  edge  of  the  bowel  is  to  be  attached  to 
the  skin;  it  is  then  made  to  transfix  the  bowel  and  brought  out  at  the 
opposite  edge  of  the  abdominal  incision  at  a  corresponding  point.  After 
two  such  sutures  have  been  passed  and  intrusted  to  an  assistant,  the 
bowel  may  be  opened  by  a  longitudinal  incision  about  three  quarters  of 
an  inch  in  length,  over  the  sutures  which  pass  across  its  calibre.  The 
middle  of  each  suture  is  then  drawn  out  of  the  bowel  and  divided.  In 
this  way  four  sutures  will  be  in  place;  and  after  they  have  been  secured, 
one  may  be  inserted  at  each  end  of  the  wound  in  the  bowel,  and  as  many 
more  along  the  sides  as  may  be  necessary  for  perfect  coaptation.  The 
sutures  should  be  of  strong  silk. 

The  operation  maybe  modified  with  advantage  by  stitching  the  parietal 

'Op.  cit.,  p.  596." 


CONGENITAL    MAXFORMATION8    OF    THE    BECnTM    AND    ANUS.  4o 

and  visceral  layers  of  the  peritoneum  together  with  sutures  passing  down 
to  the  sub-mucous  layer  of  the  bowel,  but  not  into  its  calibre.  The  wound 
may  then  be  covered,  and  the  opening  into  the  bowel  delayed  for  «x  or 
eight  hours  for  adhesions  to  occur. 

The  immediate  dange**  in  the  operation  of  lumbar  colotomy  is  that 
the  peritoneum  may  be  opened  and  death  result  from  peritonitis,  due 
not  so  much  perhaps  to  the  incision  in  the  serous  sac  as  to  the  escape  of 
•fluids  into  its  cavity.  It  has  also  happened  to  good  operators  to  open  a 
coil  of  small  intestine  instead  of  the  colon;  or,  by  missing  the  latter  at 
first  on  account  of  some  change  in  its  position,  to  become  confused  in  the 
subsequent  search  and  fail  utterly  in  finding  the  desired  part.  Both  of 
these  most  common  accidents  are  best  avoided  by  a  close  adherence  to 
the  rules  which  have  been  given. 

The  list  of  mishaps  in  connection  with  this  operation  is  a  long  and 
curious  one.  The  wound  is  deep  and  it  is  more  than  probable  that  in 
tdany  cases  the  accident  which  the  operation  is  especially  intended  to 
avoid,  and  the  avoidance  of  which  is  the  one  point  in  favor  of  the  lum- 
bar over  the  inguinal  incision — a  wound  of  the  peritoneum — is  not 
avoided.  The  portion  of  the  descending  colon  not  covered  by  perito- 
neum varies  greatly  in  extent  in  different  cases;  and  during  the  operation 
there  is  no  way  of  determining  whether  the  serous  coat  is  or  is  not  under 
the  knife.  The  kidney  has  more  than  once  been  wounded  at  the  bottom 
of  the  incision,'  and  as  good  an  operator  as  Allingham*  confesses  to  hav- 
ing opened  the  duodenum  where  it  embraces  the  head  of  the  pancreas, 
in  an  attempt  to  find  the  colon  on  the  right  side.  In  children  the  peri- 
toneal investment  is  more  complete  than  in  adults,  and  the  operation  is 
contra-indicated  both  on  this  account,  and  because  of  the  greater  mova- 
bility  of  the  intestine.  In  one  hundred  and  thirty-fOur  autopsies  on 
children  of  less  than  two  weeks  of  age,  Giraldis  found  the  sigmoid  flexure 
on  the  left  side  in  114;  Curling  in  100  found  it  so  located  in  85;  and 
Bourcart  in  117  out  of  150.' 

Inguinal  colotomy  is  especially  indicated  in  treating  imperforate 
anus  in  children,  in  whom  the  mesocolon  is  so  lax  that  the  sigmoid 
flexure  may  wander  even  across  the  aorta  into  the  opposite  flank.  He 
who  attempts  the  extra- peritoneal  operation  in  a  child  may  consider 
himself  fortunate  if  he  finds  the  desired  point  at  all;  and  when  found  it 
is  80  completely  surrounded  by  peritoneum  as  to  render  a  wound  of  the 
sac  almost  a  certainty.  The  operation  in  the  groin  too  is  easier  of  per- 
formance, and  when  successful  the  resulting  anus  is  more  easily  cared  for 
by  the  patient.  These  facts,  together  with  the  decreasing  fear  of  incising 
the  peritoneum,  have  led  some  surgeons  to  advocate  this  operation  not 


•  Bryant,  Amussat. 

»Op.  cit..  p.  230. 

»  Guyon:    Diet.  Encyc.  des  Sci.  Med.,  Paris,  1868. 


44  DI8KA8E8    OF    THE    BECTUM    AND    ANUS. 

only  in  cases  of  adults  where  disease  has  encroached  upon  the  sigmoid 
flexure,  where  it  is  particularly  indicated;  but  in  all  cases  for  which  the 
lumbar  incision  is  generally  chosen.  The  inguinal  operation  is  in  great 
favor  among  the  French,  the  lumbar  among  the  English.' 

An  incision  about  two  inches  and  a  half  long  is  made  in  the  left  groin 
parallel  with  Poupart's  ligament,  about  half  an  inch  above  it,  and  well 
towards  the  lateral  wall  of  the  abdomen — so  far  that  the  epigastric  artery 
should  not  be  seen  in  the  operation.  This  incision  is  carried  down  to 
the  peritoneum,  each  successive  layer  being  divided  on  a  director  as  is 
usual  in  operations  on  this  part.  Before  the  peritoneum  is  opened,  all 
haemorrhage  from  the  wound  should  be  stopped  and  the  cut  rendered  as 
dry  and  clean  as  possible.  The  peritoneum  is  then  pinched  up  with  for- 
ceps and  nicked,  a  director  is  introduced,  and  the  opening  enlarged  to 
the  extent  of  an  inch  and  a  half.  The  descending  colon  should  be  in. 
view  immediately  below  the  wound,  and  is  recognized  by  the  usual  sign. 
When  such  is  the  case,  the  subsequent  steps  of  the  operation  are  compa- 
ratively simple;  the  incision  into  its  wall  and  its  union  to  the  abdominal 
wound  being  accomplished  in  the  same  manner  as  already  "described  in 
the  lumbar  operation.  But  when  such  is  not  the  case,  the  bowel  must  be 
searched  for,  and  it  may  be  necessary  to  enlarge  the  original  incision. 
The  following  case  from  Molliere"  illustrates  very  well  the  difficulties 
which  may  attend  the  operation  in  an  adult  under  such  circumstances. 

**An  unfortunate  woman  was  admitted  to  the  hospital  at  night  with 
symptoms  of  acute  intestinal  obstruction.  The  abdomen  was  greatly 
distended,  but  she  asserted  that  it  had  been  much  increased  in  size  for  a 
long  time  previous.  As  death  was  imminent  and  punctures  into  the  in- 
testine through  the  abdominal  wall  gave  no  relief,  inguinal  colotomy  was 
decided  upon.  Scarcely  was  the  incision  made  into  the  peritoneum 
before  a  quantity  of  ascitic  fluid  escaped,  and  an  enormous,  white,  shiny, 
aponeurotic-looking  tumor  made  its  appearance.  This  tumor  was  some- 
what movable.  The  operator  believing  that  he  was  dealing  with  ati 
ovarian  cyst,  and  despairing  of  reaching  the  colon,  made  an  incision  into 
the  small  intestine  from  which  escaped  a  large  quantity  of  faeces.  The 
autopsy  demonstrated  later  that  this  tumor  was  itself  the  colon,  greatly 
distended  above  a  contraction  caused  by  cicatricial  bands  in  the  pelvis. 
The  patient  had  succumbed  to  a  general  tubercular  peritonitis." 

7.  Attempts  at  establishing  an  anus  in  the  anal  region  after  the  per- 
formance of  colotomy  are  attended  with  great  danger,  and  are  generally 
unsucceseful. 

'  For  discussion  as  to  the  relative  merits  of  the  two  operations  the  reader  is 
referred  to  the  following  articles:  Dupuytren,  "Diet,  en  30  vols.,"  Art.  Anus  Arti- 
ficiel;  Videl  de  Cassis,  These  de  Concours,  1842;  Guyon,  "Diet.  Encyc.  des  Sci. 
Med.,"  Paris,  1863;  Giraldes,  "  Nouv.  Diet,  de  Med.  et  de  Chir.  prat.,"  t.  ii.,  p.  633; 
Robert,  "Bull,  de  I'acad.  Roy.  de  Me:l.,"'  t.  xxi,,  p.  931. 

»  Op.  cit. 


CONGENITAL   MALFORMATIONS   OF  THK   BEOTUM    AND    ANUS.  45 

Perhaps  the  best  authority  on  this  point  is  embraced  in  the  experi- 
ence of  Mr.  Owen.'  In  two  cases  in  which  after  an  interval  of  three 
months  he  attempted  to  establish  an  anus  in  the  natural  position,  the  end 
was  a  fatal  peritonitis  due  to  the  fact  that  the  rectal  pouch  was  com- 
pletely covered  with  peritoneum.  Dr.  Byrd*  has  more  recently  reported 
a  case  in  which  the  operation  was  successful.  The  bowel  ended  in  this 
case  in  a  sort  of  cul-de-sac  with  an  appendix,  and  the  operation  is  de- 
scribed as  follows.  **  By  passing  my  finger  into  the  bowel  through  the 
wound,  I  found  that  the  calibre  of  the  bowel  easily  permitted  its  passage 
for  about  three  inches,  when  it  suddenly  narrowed,  and  from  that  point 
downward  it  resembled  the  appendix  vermiformis.  Into  this  narrowed 
portion  was  passed  a  small  sound  used  for  searching  for  stone  in  infants, 
and  the  end  of  it  worked  downward  in  the  narrowed  bowel  toward  the 
anus. 

To  more  easily  meet  the  sound  from  below,  an  incision  was  made  about 
two  inches  deep,  up  from  the  anus  and  back  to  the  coccyx,  large  enough  to 
])ermit  the  passage  of  the  index  finger.  The  sound  was  carried  along 
until  it  could  be  felt  only  about  one-eighth  of  an  inch  from  tlie  tip  of 
the  finger  passed  from  below,  when  it  would  pass  no  further  with  ease. 
Force  enough  was  then  used  to  pass  the  sound  through  the  intervening 
space,  and  the  point  Avas  brought  out  at  the  anus.  To  the  point  of  the 
sound  a  stout  thread,  running  through  a  No.  10  Jacques  catheter,  was 
attached  with  a  reef  knot,  and  the  sound  was  retracted,  bringing  the  cath- 
eter with  it.  One  end  protruded  from  the  anus,  and  the  other  from 
the  artificial  anus.  To  the  end  protruding  from  the  artificial  opening,  a 
compress  was  tied,  and  by  placing  a  bit  of  rubber  dam  under  the  com- 
press and  drawing  the  catheter  down,  extrusion  of  the  bowel  was  pre- 
vented, and  some  control  was  exerted  over  the  faeces.  The  child  was 
very  much  prostrated  by  the  shock  of  this  operation,  but,  by  the  second 
day,  he  had  fully  recovered. " 

This  plan  of  treatment  was  continued  as  follows:  The  author  took  "  a 
piece  of  soft-rubber  tubing  about  as  large  around  as  my  little  finger  and 
one  foot  long.  By  tucking  half  an  inch  of  one  end  up  into  the  tube, 
it  made  a  bulbous  end  somewhat  larger  than  the  rest  of  the  tube;  this 
end  I  fastened  to  the  catheter,  where  it  came  out  at  the  side,  with  a 
stout  flax  thread,  and  drew  it  down  into  the  bowel  by  retracting  the 
catheter.  As  I  expected  and  desired,  it  caught  against  the  shoulder  of 
the  narrowed  bowel,  and  by  traction  upon  the  catheter,  the  mucous 
membrane  was  brought  down  in  a  fold  in  front  of  the  bulb,  and  covered 
the  space  that  otherwise  would  have  been  filled  with  cicatricial  tissue.    To- 

•  Surgery  of  Childhood.  Brit.  Med.  Jour.,  Febmarj-  2l8t,  28th;  March  6th, 
1880. 

'  Lumbo-Colotomy  in  the  New-Born  for  Rehef  of  Imj^erforate  Rectum.  Read 
before  the  Tri-State  Med  Soc.,  St.  Louis.  Oct  25th,  1881.    (Reprint.) 


46  DISEASES    OF   THE   KECTDlvr    AND   ANUS. 

day  (about  one  month  after  the  introduction  of  the  rubber  tube)  I  re- 
moved the  tube,  and  find  my  little  finger  passes  readily  up  the  opening, 
which  is  covered  throughout  with  mucous  membrane." 

Unfortunately  the  history  of  this  case  ends  at  this  point,  the  author 
expressing  the  hope  that  the  artificial  anus  would  close  "  without  further 
operative  interference,  except  the  wearing  of  a  well-adjusted  pad,"  and 
being  prepared  to  perform  a  further  operation  for  its  closure  should  it 
prove  to  be  necessary. 

Kronlein  '  also  reports  a  successful  case  of  this  operation.  A  child  six 
days  old  had  had  no  evacuation  of  the  bowels  since  its  birth.  The  anus 
was  extremely  narrow  and  ended  in  a  pouch  2. 5  centimetres  long.  An 
attempt  to  reach  the  rectum  by  an  incision  through  this  pouch,  resulted 
only  in  opening  the  peritoneum,  as  was  shown  by  a  free  discharge  of 
peritoneal  fluid.  The  bowel  was  then  opened  in  the  left  groin,  and  the 
child  lived  and  thrived.  When  the  child  had  reached  the  age  of  seven 
months,  the  rectal  pouch  could  be  distinguished,  and  the  original  oper- 
ation was  again  attempted,  and  the  rectal  pouch  successfully  united  with 
lower  one.  At  the  close  of  the  report,  a  stricture  existed  at  the  place 
of  union,  but  the  larger  part  of  the  faeces  were  already  evacuated  by  the 
perineal  opening. 


i    3 


Fig.  11.  Fig.  12. 

Condition  of  bowel  after  colotomy,  showing  septum  and  course  of  faeces  (Packard). 

The  attempt  to  re-establish  an  anus  in  the  anal  region  originated 
with  Demarquay,  and  involves,  if  it  be  successful,  a  subsequent  attempt 
to  close  the  artificial  opening.  This  is  an  operation  of  great  danger 
and  one  seldom  successful.  The  difficulties  consist  in  re-establishing  the 
calibre  of  the  bowel  at  the  point  where  it  is  partially  occluded  by  the  for- 
mation of  the  artificial  opening,  and  in  subsequently  closing  this  opening 
by  a  plastic  operation.  The  danger  is  of  fatal  peritonitis.  It  is  well 
known  that  in  cases  of  colotomy,  the  side  of  the  bowel  opposite  the 
opening  becomes  sharply  bent  upon  itself,  as  shown  in  Figs.  11  and  12. 
The  septum  thus  formed  is  composed  of  two  layers,  each  consisting  of 
the  whole  thickness  of  the  intestinal  wall,  and  it  must  be  destroyed  before 
the  lumen  can  be  re-established  and  the  opening  safely  closed.  Dupuy- 
tren's^  original  operation  consisted  first  in  compressing  this  valve  by  an 
instrument  invented  by  himself,  the  action  of  which  is  shown  in  Fig.  13. 

1  Berlin.  Klin.  Woch.,  1879,  No.  34-35. 

2  Lemons  Orales  de  Clin.  Chirurgicale.     Paris,  1839,  t.  iv.,  p.  1. 


CONGENITAL   MALFORMATIONS   OF  THE    BEOTUM    AND    ANTS.  47 

This  was  applied  and  tightened  so  as  at  once  to  cause  the  death  of 
the  included  portion.  The  subsequent  steps  in  the  operation  consisted 
inclosing  the  artificial  opening.  His  experience  extended  over  41  cases, 
21  of  which  were  done  by  himself  and  20  by  others.  Three  cases  were 
fatal.  Of  the  remaining  38  the  operation  was  unsuccessful  in  8,  and  suc- 
cessful in  29  in  periods  varying  from  two  to  six  months.  It  is  but  proper 
to  say  that  considerable  doubt  exists  as  to  the  reliability  of  this  very 
favorable  showing. 

Since  his  time,  the  operation  of  Dupuytren  has  been  modified  in  vari- 
ous ways  by  different  surgeons.  Barker '  has  recently  reported  a  success- 
ful operation  after  a  plan  of  his  own,  the  essential  feature  of  which  con- 
sists in  introducing  into  the  bowel  through  the  artificial  anus,  after  the 


i      :  ' 


/ 


Fio.  13.  — Enterotome  of  Dupuytren  In  position  (Packard). 

projecting  spur  of  the  bowel  has  been  removed  in  the  usual  way,  a  thin 
and  flexible  strip  of  rubber  about  one  and  a  half  inches  long  by  five- 
eighths  of  an  inch  broad,  in  such  a  manner  as  to  lap  up  against  the  in- 
ternal orifice;  and  to  secure  this  in  position  by  a  single  wire  stitch  at 
each  end  passed  through  the  abdominal  wall.  The  object  is  to  allow  the 
rubber  to  remain  till  the  fistula  is  closed  by  paring  and  suturing  its 
edges,  and  then  by  cutting  the  wires  to  allow  it  to  pass  down  the  bowel. 
In  the  case  recorded,  the  rubber  answered  the  purpose  of  preventing 
the  escape  of  faeces  very  perfectly  for  the  first  few  days,  after  which  there 
began  to  be  leakage,  and  it  was  removed.  The  fistula,  however,  went 
on  to  complete  closure. 

'  "A  Suggested  Improvement  in  Dupuytren's  Operation  for  Artificial  Anus, 
and  a  Successful  Case  treated  by  it."    Lancet,  Dec.  18th,  1880. 


48  DISEASES    OF    THE    RECTUM    AND    ANUS. 


CHAPTER    III. 

GENERAL   RULES    REGARDING    EXAMIN  ATIOS",    DIAGNOSIS,    AND   OPERA- 
TION. 

Necessity  for  Physical  Examination. — Questions  which  may  lead  to  Diagnosis. — 
How  to  make  Examination. — Table. — Lamp.  — Instrmnent  Case. — Position  of 
Patient. — Necessity  for  Enema  before  Examination. — What  may  be  learned 
by  simple  Inspection. — Rectal  Touch. — What  may  be  discovered  by  it. — 
Bougies;  Varieties;  Authors  Bougies. — Rectal  Specula:  Van  Buren's;  Fene- 
strated; Bivalve;  Objections. — Colonoscope. -Stretching  the  Sphincter;  Pro- 
per Method  of  Performing  the  Operation;  Results. — DijSficulties  of  Diagnosis 
of  Disease  high  up  in  the  Rectum. — Manual  Examination. — What  may  be 
Learned  by  this  Method. — Preparation  of  Patient  for  Operation. — Assistants. 
— Primary  Anaesthesia. — Tliermo-Cautery. — Haemorrhage. — Rules  for  Con- 
trolling Hfemorrhage. — Cold. — Styptics. — Packing  the  Rectum. — Treatment 
after  Operation.— Dressings. — Necessity  for  Rest. — Retention  of  Urine. — Case 
of  Fatal  Retention. 

To  one  who  has  been  trained  in  the  habit  of  making  a  diagnosis  before 
undertaking  treatment  it  seems  superfluous  to  insist  upon  the  necessity  of  a 
pliysical  examination  in  cases  of  rectal  disease.  The  majority  of  patients 
who  seek  advice  for  this  class  of  troubles  come  to  the  surgeon  with  the 
diagnosis  of  piles  or  fistula  ready  at  hand,  and,  I  am  sorry  to  say,  many 
of  them  come  with  the  authority  of  some  physician  for  that  diagnosis,  in 
whom,  neyertheless,  the  merest  inspection  is  sufficient  to  prove  the  exist- 
ence of  much  more  serious,  and  often  of  incurable,  disease.  This  is  not 
due  to  ignorance,  but  to  carelessness,  to  too  great  faith  in  the  statements 
of  the  sufferers,  and  often  to  a  false  modesty  on  the  part  of  the  practi- 
tioner which  leads  him  to  accept  such  statements  in  lieu  of  a  thorough 
examination. 

The  following  case  illustrates  many  points  in  rectal  diagnosis  and 
may  be  as  useful  to  others  as  it  was  to  myself. 

Case  I, — A  young  man  appearing  in  perfect  health  was  sent  to  me  by 
Dr.  N".  M.  Shaffer,  of  New  York,  for  rectal  trouble.  He  gave  me  a  his- 
tory of  constant  discharge  from  the  bowel  and  of  some  pain  after  defeca- 
tion, but  the  discharge  was  his  chief  trouble.  On  examination  I  discov- 
ered a  fistula,  but  such  an  insignificant  subcutaneous  affair  that  I  divided 
it  on  the  spot,  recomended  a  day's  rest,  and  assured  him  that  he  would  be 
entirely  well  in  a  week  without  further  treatment.     The  fistula  was  well 


GENERAL   RULES    BEOARDINO    EXAMINATION,    DIA0N06IS,    ETO.  49 

in  a  week,  but  the  man  was  not.  He  still  complained  of  discharge  and 
some  pain,  liiough  less  than  before.  I  made  a  second  and  more  careful 
examination  and  discovered  a  perfectly  well-marked  fissure  just  above  the 
external  sphincter.  Once  more  I  assured  him  that  he  could  easily  be 
cured,  and  I  divided  the  base  of  the  ulcer  with  a  bistoury.  The  operation 
was  thoroughly  done,  for  I  was  a  little  chagrined  at  my  former  carelessness 
and  wished  to  make  sure  of  the  cure.  The  operation  was  not  followed  by 
the  slighest  relief,  and  six  weeks  were  passed  in  the  vain  hope  of  a  cure. 
I  then  did  what  should  have  been  done  in  the  first  place,  and  set  myself 
deliberately  to  make  a  complete  diagnosis.  I  etherized  the  patient,  di- 
lated his  sphincter,  and  made  a  thorough  examination  with  artificial  light. 
The  fissure  could  be  plainly  seen  and  above  it  there  was  a  polypus  of  con- 
siderable size  which  by  its  mobility  had  escaped  me  in  the  former  exami- 
nation, and  by  its  contact  with  the  surface  of  the  sore  had  prevented  a 
cure.  This  was  removed,  but  the  man  was  not  yet  cured.  The  pain 
had  all  disappeared,  but  the  discharge  from  the  bowel  still  remained  in 
diminished  quantity.  I  was  about  to  despair,  when  he  mentioned  in  the 
most  casual  way  that  he  had  had  a  good  deal  of  itching  at  the  anus  for 
some  time  back,  and  an  examination  revealed  a  moist  eczema  which  fur- 
nished the  discharge.  The  skin  disease  had  been  there  from  the  first,  but 
as  the  man  had  asserted  that  it  never  troubled  him,  I  had  paid  little  atten- 
tion to  it.  This  was  easily  cured  and  I  ultimately  had  the  satisfaction  of 
seeing  my  patient  well.  Here  then  was  rather  an  unusual  combination  of 
troubles — a  fistula,  a  fissure,  a  polypus,  and  eczema,  and  each  one  sufficient 
in  itself  to  account  for  all  the  symptoms  of  which  the  patient  complained. 
But  all  should  have  been  discovered  at  the  first  examination,  and  the 
man  should  have  been  cured  by  one  operation  instead  of  three. 

Tiie  symptomatology  alone  may  be  of  great  value  in  the  diagnosis  of 
rectal  disease;  it  is  almost  never  sufficient  in  itself  for  a  diagnosis.  There 
is  a  train  of  symptoms  common  to  almost  all  diseases  of  this  part  and 
which  infallibly  points  to  trouble  of  some  kind,  but  they  do  not  tell  what 
that  trouble  is.  The  pain  of  a  fissure  is,  perhaps,  diagnostic  of  the  fissure, 
but  it  does  not  tell  what  troubles  may  be  associated  with  the  fissure;  and 
so  it  is  in  every  otlier  affection.  For  this  reason  the  practitioner  who  at- 
tempts to  treat  a  case  of  disease  of  the  rectum  without  first  making  a 
direct  examination  uselessly  risks  his  reputation  as  a  diagnostician,  and 
in  my  own  practice  I  am  guided  by  the  simple  rule  that  patients,  male  or 
female,  who  have  not  yet  come  to  the  point  which  makes  them  willing  to 
submit  to  an  examination,  have  not  yet  reached  a  point  which  admits  of 
treatment.  An  examination,  especially  in  women,  is  sometimes  though 
not  often,  difficult  to  obtain,  and  the  dread  of  it  keeps  many  sufferers 
from  seeking  relief;  but  still  the  rule  I  have  laid  down  is  the  only  safe 
one,  and  the  sui'geon  who  allows  himself  to  be  persuaded  into  "  recom- 
mending something  for  piles  "  will  sooner  or  later  have  a  mistake  in  diag- 
4 


50 


DISEASES    OF    THE    RECTUM    AXD    AJfUS. 


nosis  laid  to  his  charge,  nor  will  the  fact  that  he  was  moved  by  consider- 
ation for  the  patient's  sensibilities  save  him  from  blame. 

I  have  often  found  that  the  best  way  to  secure  an  examination  in 
women  who  otherwise  could  not  be  brought  to  consent  to  it,  was  to  re- 
sort to  ether,  Avith  the  understanding  that  whatever  surgical  procedure 
was  thought  advisable  should  be  performed  at  the  same  time.  In  this 
way  a  patient's  sensibilities  may  often  be  spared,  while  both  diagnosis  and 
treatment  are  included  in  one  examination. 


Before,  however,  proceeding  to  make  the  physical  examination  which 
is  inevitable,  certain  questions  and  answers  may  give  the  surgeon  a  pretty 
clear  idea  of  what  he  is  about  to  find.  It  is  generally  a  good  plan  to 
allow  an  intelligent  patient  to  tell  his  or  her  owa  history,  and  then  to 
supplement  it  with  appropriate  questions  as  to  the  length  of  time  since 
the  trouble  began;  the  character  of  pain  when  present,  whether  constant 
or  intermittent,  and  increased  by  defecation;  whether  it  comes  with  the 
stool,  immediately  or  some  time  after,  and  its  duration.     The  question  of 


OENEBAL   RULES   REOABDINO    EXAMINATION,    DIAGNOSIS,    BTO. 


51 


discharge  should  also  be  inquired  into — its  quantity  and  character, 
whether  blood,  pus,  or  mucus;  also  whether  there  is  any  protrusion  of 
any  kind,  and  its  character.  The  answers  to  these  questions  and  to  those 
which  relate  to  the  presence  or  absence  of  diarrhuea,  constipation,  and 


Fio.  10.— Lamp  for  rectal  examinationa. 


incontinence,  will  generally  give  the  surgeon  a  fair  idea  of  the  nature  of 
the  case  before  him. 

How,  then,  to  proceed  to  make  a  rectal  examination  which  shall  be 
at  the  same  time  thorough  and  as  free  from  ])ain  as  possible?  Two 
things  arq  necessary  above  all  others — a  good  bed  or  table  and  a  good 
light.     For  a  table,  a  strong,  four-legged  one,  upholstered  with  hair  and 


52 


DISEASES    OF   THE    KECTUM    AND    ANTJS. 


?f 


leather,  answers  every  purpose.  It  should  be  hard,  without  springs,  and 
about  thirty  inches  in  height.  In  place  of  this,  any  of  the  examining 
tables  of  the  gynaecologists  may  be  used.  In  my  own  oflBce,  I  use  a  modifica- 
tion of  the  combined  table  and  lounge  of  Dr.  J.  L.  Little,  which  is  rep- 
resented, closed  and  open,  in  Fig.  14  and  Fig.  15.  Its  great  advantage 
is  that,  when  not  in  use,  it  answers  as  an  ordinaiy  piece  of  furniture,  and 
when  raised  it  provides  a  firm,  hard  operating  table  of  convenient 
height.  Either  natural  or  artificial  light  may  be  used,  but  the 
latter  is  on  some  accounts  preferable,  being  always  at  command, 
and  easily  thrown  up  the  bowel  or  concentrated  upon  a  2)p,rticular 
point.  To  do  this,  a  forehead  mirror  is  requisite.  The  lamj) 
which  I  have  found  most  convenient  is  a  modification  of  Tobold's,  as 


FiQ.  17.— Case  for  rectal  instruments,  with  sliding  cover  A  A. 


represented  in  Fig.  16.  The  whole  apparatus  is  easily  moved  to  any 
part  of  the  room,  and  is  not  cumbersome;  and  with  the  lens  a  very 
powerful  illumination  is  always  attainable. 

The  instruments  necessary  are  specula  of  various  forms,  bougies,  a 
Davidson's  syringe,  ointment,  cotton,  sponge-holders,  towels,  basins,  etc. ; 
and  these  should  all  be  placed  within  easy  reach  of  the  hand.  A  con- 
venient case  for  these  things  and  for  other  surgical  instruments,  which 
is  intended  to  stand  on  the  floor  by  the  side  of  the* table  or  bed,  is  repre- 
sented in  Fig.  17. 

The  position  in  which  the  patient  should  be  placed  is  a  matter  of 
some  importance.  For  mere  inspection  of  the  anus  and  surrounding 
parts,  the  dorsal  decubitus  answers  every  purpose,  and  a  digital  exam- 
ination of  the  rectum  may  be  made  either  in  this  posture  or  with  the 
patient  on  the  side.     For  a  speculum  examination  or  the  passage  of  a 


GENERAL    RULES    REGARDING    EXAMINATION,    DIAGNOSIS,  ETC.  53 

bougie,  the  patient  should  be  placed  on  the  side,  with  the  buttocks  well 
elevated,  the  thigh  which  is  uppermost  strongly  flexed  on  the  abdomen, 
and  the  breast  resting  on  the  table.  In  this  way,  the  weight  of  the 
abdominal  contents  fulls  upon  the  front  wall  of  the  abdomen,  and  not 
upon  the  jjclvis,  and  the  lumen  of  the  Taowel  is  not  so  firmly  closed,  nor 
is  the  mucous  membrane  so  firmly  forced  into  the  end  of  the  speculum. 

Before  commencing  an  examination,  the  bowel  should  be  emptied, 
cither  by  the  natural  effort  of  the  patient  or  by  an  enema,  and  for  this 
reason  a  water-closet  in  connection  with  the  examining  room  is  indis- 
pensable to  the  practitioner  in  rectal  disease.  In  this  way,  the  patient 
may  come  directly  from  the  closet  to  the  table  with  the  parts  in  the  best 
condition  for  inspection;  and  great  additional  confidence  is  acquired, 
especially  by  women,  that  the  examiner's  frequent  reiteration  to  "bear 
down  "  will  not  be  followed  by  untoward  consequences.  The  point  may 
<eem  trivial,  but  the  fear  of  an  accident  will  frequently,  in  women, 
result  in  a  firmly  closed  sphincter,  which  no  word  of  the  surgeon  can 
overcome,  and  a  thorough  examination  cannot  be  made  while  the  recta- 
pouch  is  filled  with  faeces.  This  is  not  merely  a  thing  to  be  observed  for 
the  cleanliness  of  the  examiner,  for  the  act  of  defecation  will  bring 
internal  haemorrhoids  and  prolapse  to  the  light,  and  may  greatly  assist  in 
the  diagnosis  of  other  maladies.  In  examination  with  a  speculum,  it  is 
indispensable  to  cleanliness. 

A  simple  inspection  of  the  anus  and  adjacent  skip  and  mucous  mem- 
brane is  often  sufficient  for  a  diagnosis,  though  it  should  never  be  trusted 
to  alone.  External  haemorrhoids  and  internal  ones  when  brought  down 
by  the  use  bf  the  closet  or  enema,  external  fistulae,  ulceration,  skin  dis- 
eases, many  venereal  affections,  pin  worms,  abscess,  and  fissure,  may  all 
be  recognized  in  this  way.-  A  glance  at  the  anus,  too,  may  indicate  to 
the  practised  eye  the  existence  of  serious  disease  within  the  rectum 
proper,  for  a  discharge  may  flow  from  it  which  marks  ulceration  above, 
iiiid  it  may  be  relaxed  and  patulous  from  over-distention  or  partial 
'struction  of  the  sphincter.  A  sunken  condition  of  the  ischio-rectal 
fossae,  and  a  retracted  anus  surrounded  by  a  profusion  of  soft,  fine  hair, 
may  also  properly  excite  a  suspicion  either  of  grave  rectal  disease  or  of 
some  constitutional  affection  which  is  causing  emaciation. 

By  using  gentle  force  in  pulling  the  anus  open  with  the  fingers,  the 
mucous  membrane  may  be  everted  to  a  considerable  degree,  especially  if 
the  patient  can  be  brought  to  assist  by  an  effort  at  bearing  down.  In 
tliis  way  a  fissure  may  almost  always  be  brought  into  view  without  the 
use  of  a  speculum  of  any  sort,  and  the  internal  opening  of  the  great 
majority  of  fistulae  may  be  reached,  with  a  good  view  of  the  radiated 
folds  and  liicunae. 

Dr.  Storer,'  of   Boston,  has  described  a  method  of  examining  the 

'  Lancet,  May  31st,  1S73. 


54  DISEASES    OF   THE   KECTUM   AND    ANUS. 

mucous  membrane  just  within  the  anus,  which  is  applicable  only  in 
women  who  have  a  lax  sphincter.  It  consists  in  everting  the  mucous 
membrane  by  pressing  it  out  of  the  anus  by  the  index  finger  in  the 
vagina.  In  a  case  in  which  the  manoeuvre  can  be  practised  successfully 
and  without  too  much  pain,  a  small  portion  of  the  anterior  wall  of  the 
rectum  may  be  brought  into  view.  The  pessary  of  Gariel  has  also  been 
used  for  the  same  purpose.  It  consists  of  a  rubber  ball,  which  is  intro- 
duced empty  into  the  rectal  pouch,  then  inflated  by  means  of  a  tube 
attached  to  it,  and  withdrawn  with  some  force,  the  mucous  membrane 
being  prolapsed  in  front  of  it.  But  neither  of  these  two  procedures  is  of 
any  great  value. 

After  having  examined  the  anus  in  this  way,  the  surgeon  next  pro- 
ceeds to  the  more  difficult  task  of  examining  the  rectum,  an  operation 
which  may  be  done  skilfully  and  almost  painlessly,  or  awkwardly  and 
with  great  suffering.  The  rectum  may  be  explored  e'lther  by  the 
touch  alone,  or  by  vision  alone,  or  by  both  combined.  The  former  is 
the  simpler  and  more  painless  method,  and  with  practice  may  be  made 
to  afford  all  the  information  which  can  be  gained  by  the  two  combined. 

To  practise  the  rectal  touch,  the  nail  of  the  index  finger  should  be 
well  trimmed,  and  the  finger  lubricated  with  some  tenacious  oil.  Olive 
oil  is  much  better  than  vaseline,  the  latter  being  too  easily  rubbed  off  by 
the  sphincter.  The  condition  of  the  spincter  muscle  is  first  to  be  noted. 
Its  resistance  should  be  overcome  by  a  slow  and  steady  pressure  with  the 
ball  of  the  finger,  and  not  by  a  sudden  exertion  of  force,  for  such  an 
attack  is  always  met  by  increased  contraction.  The  force  of  the 
muscle  will  be  found  to  vary  greatly  in  different  people.  In  the  aged 
or  debilitated  it  is  lax;  in  the  strong  and  healthy  it  is  the  opposite,  and 
the  finger  can  scarcely  be  passed  through  it  without  great  pain  and 
sometimes  a  slight  laceration  of  the  tender  mucous  membrane.  "When 
inclined  to  spasmodic  contraction,  as  it  sometimes  is  in  persons  of 
nervous  tendency,  a  satisfactory  examination  may  be  impossible  without 
*Jie  use  of  ether,  on  account  of  the  pain. 

Unless  an  obstruction  is  encountered,  the  finger  may  be  carried  up 
the  bowel  its  full  length,  and  pressed  as  far  as  possible  beyond  this 
point.  Additional  distance  may  be  gained  by  passing  the  three  remain- 
ing fingers  backward  along  the  inter-gluteal  groove,  instead  of  closing 
them  in  the  palm,  as  is  generally  done,  and  pressing  the  knuckles 
against  the  soft  parts;  for  the  knuckles  prevent  the  full  passage  of  the 
index  finger. 

In  this  way  three  or  three  and  a  half  inches  of  the  rectum  may  be 
carefully  explored,  together  with  the  prostate,  the  neck  of  the  bladder, 
the  uterus,  and  the  anterior  surface  of  the  coccyx  and  lower  part  of  the 
sacrum.  With  an  exceptionally  long  finger  it  may  even  be  jiossible  to 
feel  the  vesiculse  seminales  and  vasa  deferentia.  In  other  words,  all  that 
part  of  the  bowel  which  is  most  subject  to  disease  is  brought  within  reach. 


OENEKAL    KLLES    REOARDINO    EXAMINATION,    DIAGNOSIS,  ETC.  55 

But  after  this  is  done  the  examiner  may  be  no  wiser  than  before,  for  to 
appreciate  fully  the  condition  of  the  rectum  by  the  sense  of  touch  alone 
requires  a  facility  in  this  method  of  exploration  which  most  practitioners 
never  attain.  In  the  majority  of  cases  a  digital  examination  will  be  made 
to  discover  whether  or  not  the  patient  is  suffering  from  internal  haemor- 
rhoids, and  in  the  majority  of  cases  also  the  examiner  will  be  no  wiser  on 
this  point  after  than  before,  for  a  soft  internal  haemorrhoid  is  a  difficult 
thing  to  detect  by  the  finger  alone,  being  readily  mistaken  for  the  natural 
mucous  membrane  of  the  part,  esi)ecially  when  the  latter  is  abundant  and 
gathered  into  folds,  as  it  is  apt  to  be. 

Ulceration  is  another  condition  which  it  is  sometimes  difficult  to 
detect,  especially  when  superficial  and  not  attended  by  much  induration; 
and  so  is  the  opening  of  a  blind  internal  fistula;  and  yet,  so  well  educated 
may  the  finger  become  that  other  methods  of  examination  may  be  almost 
completely  discarded.  To  carry  diagnosis  to  this  point  it  is  first  neces- 
sary by  oft  repeated  examinations,  to  become  perfectly  familiar  with  the 
feel  of  the  normal  bowel.  After  this  knowledge  has  been  gained,  a  gentle 
sweeping  of  the  ball  of  the  finger  over  the  whole  inner  surface  of  the 


,  TIE  MANN  &  CU  . 

Yva.  18. 

lower  three  inches  of  the  rectum  will  detect  any  cnange  in  it,  however 
slight.  I  wish  it  were  possible  to  describe  plainly  the  different  sensations 
which  are  conveyed  by  the  different  pathological  conditions,  but  this  is  a 
thing  each  practitioner  must  learn  for  himself  by  practice. 

A  stricture  of  small  calibre  cannot  easily  be  mistaken,  though  one 
which  admits  the  finger  without  constricting  it  may  easily  be  overlooked. 
A  stricture  small  enough  to  engage  the  end  of  the  index  finger  firmly, 
marks  the  limit  of  safe  digital  examination,  and  the  finger  should  not  be 
forced  through  it  for  the  sake  of  feeling  what  is  above,  for  an  attempt  to 
do  this  has  been  followed  by  a  fatal  rupture  of  the  bowel.  In  case  of  a 
tumor  of  any  kind,  advantage  may  be  taken  of  conjoined  manipulation 
through  the  vagina  in  the  female,  but  these  are  the  troubles  most  rarely 
met  with,  and  most  easily  diagnosticated  when  encountered.  The  cervix 
or  fundus  of  the  uterus,  when  pressing  upon  the  bowel,  may  be  distinctly 
felt  with  the  finger  in  the  rectum,  and  may  deceive  the  unwary  into  a 
diagnosis  of  a  new  growth.  The  i)rostate  may  do  the  same.  The  differ- 
ent varieties  of  ulceration  have  each  their  peculiar  and  often  diagnostic 
feel. 

For  examination  by  the  sense  of  touch  above  the  reach  of  the  finger, 
recourse  may  be  had  to  bougies.     These  are  of  all  forms,  sizes,  and 


56 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


materials,  and,  in  general  words,  the  softer  the  instrument  the  better  it 
is  for  examination.  I  much  prefer  the  black  rubber  instrument,  with  the 
blunt  point  (Fig.  18),  which  may  readily  be  bent  into  a  circle  in  the 
hand,  to  all  others  in  the  market,  and  the  same  instrument  comes  with 
a  sharp  point  (Fig.  19)  which  sometimes  answers  a  good  purpose.    These 


CLTJEMANU  &C0. 
Fig.  19. 

instruments  are  made  in  twelve  different  sizes,  and  for  the  purpose  of 
diagnosis  the  medium-sized  is  the  best.  The  old-fashioned  red,  hard- 
rubber  bougie  is  unnecessarily  stiff  and  dangerous,  and  should  be  dis- 
carded, having  no  advantages  over  the  softer  ones  either  for  the  purpose 
of  diagnosis  or  for  that  of  treatment.  The  bougie  a  houle,  made  of  hard- 
rubber  with  a  flexible  whalebone  handle,  is  a  favorite  instrument  with 
many.     (Fig.  30.) 


Flo.    23. 

For  my  own  use  I  have  had  a  kind  of  bougie  made  by  Messrs.  Stohl- 
mann,  Pfarre  &  Co.,  which  I  prefer  to  all  others,  for  the  simple  reason 
that  it  is  softer  and  more  flexible  than  any  in  the  market.  It  is  made  of 
the  same  material  as  the  red  soft-rubber  catheters,  and  differs  from  them 
only  in  size  and  in  the  thickness  of  its  walls.  With  such  an  instrument 
one  is  pretty  certain  not  to  perforate  the  bowel,  and  for  diagnosis  it 
answers  every  purpose  as  well  as  the  harder  instruments.  The  better 
fitted  a  bougie  is  for  pushing  its  way  through  a  stricture  the  worse  it  is 
for  rectal  exploration. 

These  instruments  are  all  used  for  the  same  purpose — that  of  feeling 
for  a  stricture  located  above  the  reach  of  the  finger;  and  with  any  of  them 
the  unpractised  hand  will  generally  detect  an  obstruction  in  the  perfectly 


GENERAL   RULES    REGARDING    EXAMINATION,    DIAGNOSIS,    ETC.  57 

healthy  bowel  at  about  four  inches  from  the  anus.  I  have  had  patients 
iu  whom  I  liave  never  been  able  to  pass  any  sort  of  a  bougie  without  first 
injecting  the  rectum,  no  matter  what  manceuvering  I  resorted  to;  and 
I  liave  seldom  told  a  student  to  pass  a  rectal  bougie  that  he  did  not  at 
once  discover  a  stricture.  To  pass  a  bougie  into  the  rectum  is  rather  a 
more  diflBcult  operation  than  to  pass  one  into  the  urethra,  the  triangular 
ligament  in  the  latter  being  replaced  by  the  curves,  the  folds  of  mucous 
membrane,  and  the  promontory  of  the  sacrum  in  the  former.  Indepen- 
dent of  Houston's  valves  of  mucous  membrane,  it  is  not  improbable  that 
a  slight  degree  of  invagination  of  the  upper  into  the  lower  part  of  the  rec- 
tum may  often  exist;  and  into  the  sulcus  formed  by  this  condition 
the  point  of  the  bougie  "may  easily  pass.  For  the  sake  of  overcoming 
these  folds  of  membrane  the  most  minute  directions  have  been  given  as 
to  how  the  bougie  should  be  introduced  and  gently  urged  along  each  suc- 
cessive inch  of  the  bowel'  by  changing  its  direction  and  manipulating 
the  handle.  But  such  rules  are  of  little  value,  for  the  simple  reason  that 
the  obstruction  is  seldom  of  the  same  kind  or  in  the  same  place  in  two 
different  persons.  Esmarch'  gives  the  general  rule  that  the  patient 
should  lie  on  the  left  side,  as  the  chief  and  most  constant  fold  of  mem- 
brane, the  plica  transversalis  recti  of  Kohlrausch,  projects  from  the  right 
wall.  The  instrument  should  be  passed  gently,  for  force  is  never  allow- 
able here  more  than  in  the  similar  operation  on  the  urethra;  and  when 
an  obstruction  is  met  with  the  handle  should  be  gently  rotated,  with- 
drawn, and  again  passed  onward  till  by  frequent  repetitions  of  this 
mancBuvre  it  is  made  to  pass.  If  this  does  not  suffice,  a  Davidson's 
syringe  may  be  attached  to  the  lower  end  of  the  bougie  and  a  stream  of 
warm  water  thrown  into  the  bowel  until  it  is  moderately  distended  when 
tliu  bougie  will  generally  pass  with  ease. 

For  measuring  the  extent  of  a  stricture,  an  ingenious  instrument  has 
been  devised  by  Laugier,  which  consists  in  attaching  a  thin  rubber  glove- 
finger  to  the  end  of  a  perforated  bougie.  This  is  passed  up  the  bowel 
empty,  and  then  inflated  and  withdrawn  till  it  reaches  the  upper  limit  of 
the  obstruction.  It  is  safer  than  the  bougie  a  botilc,  for  it  may  be  allowed 
to  collapse  before  being  withdrawn,  and  all  straining  of  the  diseased  tis- 
sues may  thus  be  avoided. 

In  case  disease  actually  exists  high  up  in  the  bowel,  the  attempt  to 
pass  an  instrument  is  full  of  danger.  A  patient  may  easily  recover  from 
a  false  passage  made  in  the  urethra,  but  such  will  seldom  be  the  case  with 
the  rectum,  for  hero  when  the  instrument  leaves  the  bowel  it  enters  the 
peritoneum.  To  understand  this  danger  it  is  only  necessary  to  remem- 
ber that  the  bowel  is  generally  ulcerated  both  above  and  below  the  seat 

'  Houston:   "  Dublin  Hosp.  Reports,"  vol.  v.,  1830. 

*Die  Krankheiten  des  Mastdarmes  und  dee  Afters,  Pitha  und  Billroth's 
Clxirurgie. 


58  DISEASES    OF    THE    RECTUM    AND    ANUS. 

of  the  contraction,  and  is  sometimes  weakened  to  such  an  extent  that  it 
will  allow  a  bougie  to  pass  through  it  without  the  use  of  any  ai^preciable 
force  on  the  part  of  the  surgeon.  The  bowel  may  also  be  lacerated  with- 
out being  directly  perforated  by  the  bougie,  for  the  stricture  may  be 
pushed  upward  or  dragged  downward  on  the  point  of  the  instrument  till 
the  bowel  gives  way. 

Supposing,  now,  that  a  rectal  bougie  cannot  be  passed  eight  or  ten  inches 
up  the  bowel,  is  it  safe  on  this  account  alone  to  make  a  diagnosis  of  stric- 
ture high  up  ?  I  should  hesitate  long  before  doing  so,  and  should  make 
many  careful  attempts  to  pass  the  instrument  at  different  times,  resorting 
to  injection  if  necessary,  carefully  exploring  through  the  abdominal  wall 
for  induration,  and  watching  for  the  usual  signs  of  obstruction.  There 
are  one  or  two  points  worthy  of  remembrance  in  this  connection.  The 
first  is  that  the  obstruction  due  to  a  stricture  will  always  be  at  the  same 
point  in  the  canal;  and  another  is,  that  when  a  bougie  has  once  become 
engaged  in  a  stricture  it  is  firmly  grasped,  and  the  resistance  to  its  with- 
drawal is  equal  to  that  encountered  in  introducing  it  farther.     The  feel- 


FiG.  21.— (Van  Buren). 

ing  conveyed  to  the  hand  under  these  circumstances  is  diagnostic,  and  is 
like  that  which  is  felt  when  the  effort  is  made  to  withdraw  a  sound  from 
the  grasp  of  a  stricture  in  the  urethra. 

Should  it  still  be  necessary  for  diagnosis,  the  speculum  may  be  used 
and  the  inside  of  the  rectum  illuminated.  I  have  postponed  any  refer- 
ence to  this  means  of  examination  till  the  present,  because  it  will  gener- 
ally be  found  useful  only  after  the  others  have  been  tried.  The  thorough 
use  of  the  speculum  involves,  almost  of  necessity,  the  administration  of 
ether  and  the  stretching  of  the  sphincter  muscles;  to  try  to  use  it  with- 
out these  adjuncts  is  almost  to  inflict  useless  pain  upon  the  patient.  I 
shall  not  attempt  any  description  of  the  infinite  number  of  instruments 
which  have  been  invented  for  this  purpose,  or  any  judgment  upon  their 
relative  advantages,  but  will  merely  say  that  the  best  vaginal  speculum  is 
still  the  best  for  the  rectum — that  of  Sims,  with  a  groove  where  the  blade 
joins  the  handle  for  the  sphincter  to  rest  in  as  suggested  by  Van  Buren, 
Fig.  21.  The  fenestrated  instrument,  Fig.  22,  is  sometimes  useful  for 
inspecting  the  parts  just  within  the  anus;  and  a  long  vaginal  C3dindrical 


GENERAL   BULES   REGARDING    EXAMINATION,    DIAGNOSIS,    ETC.  59 

speculum,  with  the  end  cut  at  such  an  angle  as  will  best  expose  the 
mucous  membrane,  may  sometimes  be  of  service  in  bringing  into  view  a 
small  portion  of  the  inner  surface  of  the  bowel  high  up.  But,  after  all 
liave  been  tried,  none  will  be  found  better  for  any  purpose  than  a  small- 


Fio.  ai 


bladed  Sims's,  and  without  ether  all  will  be  found  eminently  unsatisfac- 
tory. 

Almost  the  only  other  speculum  besides  Sims's  which  I  have  found  of 
any  practical  value  is  the  bivalve  shown  in  Fig.  23,  but  the  same  objec- 


Fio.  8S. 

tion  applies  to  this  as  to  all  the  others,  that  the  redundant  mucous  mem- 
brane  prolapses  between  the  blades  to  such  an  extent  as  to  render  it 
almost  useless,  and  that  when  the  attempt  is  made  to  dilate  the  blades 
suflBciently  to  overcome  this,  the  sphmcter  is  immediately  stretched  to  a 
painful  extent.  With  any  speculum  the  wooden  depressor,  shown  in 
Fig.  24,  may  be  found  a  useful  addition. 


Fio.  24.— Rectal  Depressor  (Van  Buren). 


The  idea  of  th,e  endoscope  has  been  aj)plied  to  the  rectum  in  the  use  of 
tl|B  instrument  shown  in  Fig.  25.     It  is  of  little,  if  any,  practical  value. 


60 


DISEASES   OF   THE   RECTUM   AND   ANUS. 


however;  its  introduction  beyond  the  point  which  can  be  reached  by  a 
long  vaginal  speculum  being  exceedingly  difficult,  and,  in  case  of  the  dis- 
eases which  it  is  supposed  to  enable  the  surgeon  to  see,  not  devoid  of 
danger;  and  the  mirror  quite  useless. 

It  is  almost  useless  to  attempt  to  see  within  the  rectum  with  any  kind 
of  a  speculum  without  first  overcoming  the  sphincter  muscle,  and  the  only 
effectual  way  of  doing  this  is  by  stretching  it.  It  is,  therefore,  my  own 
practice  to  resort  to  this  procedure  in  every  case  of  doubtful  character, 
nor  was- 1  led  to  this  practice  without  many  trials  of  the  various  speculae 
in  the  market,  all  ending  in  disappointment.  The  stretching  of  the 
sphincter  is  in  itself  an  entirely  harmless  proceeding,  but  one  which  neces- 
sitates the  previous  administration  of  ether.  It  should  not,  however,  be 
done,  as  was  at  one  time  the  usual  method,  and  as  it  is  often  done  at 
present,  by  introducing  the  thumbs  back  to  back,  and  forcibly  and  sud- 
denly separating  them  till  they  touched  the  tuberosities  on  each  side.  In 
this  way,  the  mucous  membrane  is  often  lacerated  at  one  or  more  points, 


Fig.  25.— Colonoscope  of  Bodenhamer. 
• 

and  the  paralysis  is  not  as  effectual  as  when  the  stretching  is  done  more 
gradually.  A  better  way  is  to  introduce  first  one  finger,  then  two,  and 
finally  four,  in  the  form  of  a  funnel  and  gradually  bore  into  the  anus ;  or  to 
introduce  two  fingers,  and  make  pressure  on  all  sides  of  the  opening  till 
it  becomes  patulous.  Instead  of  one  or  two  seconds,  this  procedure 
should  occupy  five  minutes,  and  should  be  done  so  gently  as  not  to  lacer- 
ate the  mucous  memb'rane.  The  dilatation  should  also  be  made  to  include 
the  internal  as  well  as  the  external  muscle.  If  this  dilatation  be  carried  to 
a  sufficient  extent,  the  firm,  cord-like  feel  of  the  external  sphincter  may 
be  made  to  completely  disappear.  The  paralysis  induced  in  this  way  is 
always  temporary,  and  I  have  never  known  it  to  be  followed  even  by  a 
temporary  incontinence  of  faeces.  After  coming  out  of  the  ether,  the 
patients  are  usually  conscious  of  only  a  sense  of  soreness  in  the  part,  but 
are  never  incapacitated  for  their  usual  duties.  This  stretching  of  the 
sphincters  is  a  necessary  preliminary  in  almost  all  operations  within  the 
rectum. 

With  the  patient  in  the  proper  position  on  the  side,  under  the  influence 


GENERAL    RULES    RBOARDINO    EXAMINATION,    DIAGNOSIS,    BTO.  61 

of  ether,  with  the  spiiincter  thoroughly  dilated,  and  with  a  good  reflected 
light,  the  lower  four  or  five  inches  of  the  rectum  may  be  thoroughly 
illuminated  and  examined.  A  couple  of  inches  more  may  be  seen  by  the 
use  of  the  cylindrical  speculum,  with  the  patient  standing  and  bending  for- 
ward over  the  table,  and  assisting  the  examiner  by  straining  down  ;  and  in 
this  way  a  stricture  may  sometimes  be  brought  into  view  which  could  not 
be  seen  with  the  Sims's  speculum  alone. 

As  a  rule,  however,  a  speculum  will  be  found  of  very  little  use  in  the 
examination  of  stricture,  but  is  chiefly  available  for  obtaining  a  good 
view  of  other  morbid  processes  afifecting  the  rectal  pouch  and  for  making 
applications  to  them  or  performing  operations  for  their  cure.  By  its 
aid  the  different  varieties  of  ulceration  may  be  inspected  and  thus  dif- 
ferentiated, the  internal  openings  of  fistulae  may  be  located,  and  the 
whole  rectal  pouch  may  be  brought  into  view. 

From  what  has  been  said  it  may  readily  be  seen  that  the  diagnosis  of 
stricture  above  the  reach  of  touch  or  vision  is  a  difficult  matter.  So  dif- 
ficult is  it  in  some  cases  that  no  less  an  authority  than  Syme  has  written 
that  there  is  good  reason  to  suspect  the  honesty  of  a  man  who  pretends 
to  detect  such  a  condition.  Such  is,  indeed,  the  case,  for  ''strictures 
high  up  "  are  favorites  among  a  certain  class  of  quacks,  and  the  passage 
of  a  bougie  two  or  three  times  a  week  for  an  indefinite  period  is  profit- 
able business.  In  reality  stricture  above  the  rectal  pouch  is  rare;  when 
they  exist  they  are  usually  malignant,  for  this  part  of  the  bowel  is  not 
subject  to  the  influences  which,  by  exciting  ulcerative  action,  result  in 
the  cicatricial  contractions  which  so  often  affect  the  lower  three  inches  of 
the  rectum ;  and  malignant  disease  of  the  sigmoid  flexure  or  descending 
colon  will  manifest  itself  by  a  well-marked  train  of  constitutional  and 
local  symptoms,  and  can  generally  be  felt  better  through  the  abdominal 
wall  than^er  rectum. 

After  the  use  of  the  bougie,  which  is  at  best  an  uncertain  means  of 
diagnosis  for  this  condition,  and  after  a  study  of  the  symptomatology, 
and  a  careful  examination  through  the  abdominal  wall,  there  is  still  one 
other  means  of  exploration  open  to  the  surgeon  if  he  have  a  sufficiently 
small  hand — the  passage  of  the  whole  hand  into  the  rectum.'  A  hand 
which  measures  seven  and  a  half  inches  in  circumference  can  gen- 
erally be  passed  easily ;  one  measuring  more  than  nine  is  unfit  for  the 
purjKJse.  With  a  small  hand  there  is  no  danger  of  permanent  incontin- 
ence of  faeces,  but  the  sphincter  should  be  dilated  gently  and  gradually, 
rather  than  forcibly  torn  open. 

When  the  anus  has  been  sufficiently  dilated  to  allow  the  hand  to  enter 

'  G.  Simon,  Ueber  the  kQnstliche  Erweiterung  des  Anus  und  Rectum. 
Arch.  £.  klin.  Chir.,  xv.,  1,  1872;  Dtsch.  Klin.  f.  Chir.,  Nov.,  1882;  W.  J. 
Walshara,  Some  Remiirks  on  the  Intro<luction  of  the  Whole  Hand  into  the 
Rectum,  St.  Bartholomew's  Hosp.  Rep.,  vol.  xii.,  1876,  p.  223. 


62  DISEASES    OF    THE    RECTUM    AND    ANUS. 

the  rectum,  if  the  bladder  is  empty,  the  arch  of  the  pubes  may  be  felt 
above  the  prostate,  if  full  it  will  be  easily  distinguished  at  the  same  point. 
The  uterus  and  ovaries  are  easily  made  out  anteriorly,  and  the  whole 
curve  of  the  sacrum  may  be  followed  posteriorly.  The  next  point  to  feel  for 
IS  the  spine  of  the  ischium  on  either  side,  and  with  this  as  a  guide,  the 
greater  and  lesser  sciatic  notches  may  be  outlined.  The  whole  brim  of  the 
pelvis  may  be  traced,  and  the  external  and  internal  iliac  arteries  followed 
with  the  fingers.  All  this  may  be  done  while  the  hand  is  in  the  rectal 
pouch,  and  it  may  be  done  upon  almost  any  patient,  male  or  female, 
though  more  easily  upon  the  female,  with  a  small  hand,  without  causing 
any  unpleasant  after-results.  But  in  many  persons  this  is  all  that  can  be 
gained  by  this  method,  for  the  anatomical  reason  that  to  pass  the  hand 
above  into  the  sigmoid  flexure  is  often  attended  with  great  danger  from 
the  narrowing  of  the  bowel  at  this  point.  AYhen  the  hand  is  met  by  a 
sense  of  constriction  at  about  the  level  of  the  third  sacral  vertebra,  where 
the  lateral  fold  of  Douglas  is  reflected  from  the  bowel,  the  limit  of  ex- 
amination has  been  reached,  and  no  force  should  be  used  to  overcome 
the  constriction,  which  can  only  be  accomplished  by  a  rupture  of  the 
peritoneal  coat.  In  many  cases,  however,  by  carefully  following  the 
natural  windings  of  the  canal,  and  by  a  semi -rotatory  movement  of  the 
hand,  combined  with  alternate  flexing  and  extending  of  the  fingers,  this 
point  of  danger  may  be  surmounted,  and  the  hand  be  passed  fairly  into 
the  sigmoid  flexure,  and  sometimes  into  the  descending  colon.  Here 
the  comon  iliacs,  the  bifurcation  of  the  aorta,  the  left  kidney,  and,  m 
fact,  nearly  all  of  the  abdominal  contents  may  be  touched. 

By  this  method  of  examination,  a  stricture  situated  in  the  sigmoid 
flexure,  or  even  m  the  descending  colon,  may  sometimes  be  discovered 
after  all  other  methods  of  examination  have  failed ;  but,  as  we  have 
shown,  the  method  is  not  always  applicable,  and  the  diagnosis  of  stric- 
ture high  up  still  remains  one  of  the  most  difficult  things  in  surgery.  In 
the  great  majority  of  cases  in  general  practice,  in  which  such  a  diagnosis 
has  been  made,  it  may  be  proved  false  by  the  introduction  of  a  full-sized 
bougie  after  a  few  trials,  and  in  the  remainder  the  diagnosis  will  be  con- 
firmed sooner  or  later  by  the  well-marked  symptoms  of  intestinal  ob- 
struction. 

Before  attempting  any  surgical  operation  upon  the  rectum,  the  bowels 
should  be  thoroughly  emptied  by  a  cathartic.  It  is  well  to  begin  with 
three  compound  cathartic  pills,  or  with  five  grains  of  mass,  hydrarg.  on 
the  second  evening  before  the  operation  where  the  patient's  general  con- 
dition admits  of  these  remedies;  to  follow  them  with  a  slight  saline  or  a 
dose  of  castor  oil  on  the  night  immediately  preceding;  and  finally  to  clear 
out  the  rectum  with  a  simple  enema  on  the  morning  of  the  day  of  the 
operation.  After  this  the  bowels  may  easily  be  confined  for  a  week  if 
desirable  without  inconvenience  to  the  patient,  and  the  passage  of  hard 
masses  of  faeces  over  a  wounded  surface  is  avoided. 


GENERAL    RULES    RBOARDINO    EXAMINATION,    DIA0N08IB,    BTO.         63 

In  all  operations  in  which  ether  is  used,  three  assistants  will  be  neces- 
sary and  four  are  preferable.  Each  assistant  should  have  his  place  as- 
signed to  him — one  for  the  anaesthetic,  one  to  keep  each  leg  of  the  patient 
in  position  and  to  hold  the  speculum,  and  one  to  assist  the  operator  in 
whatever  way  may  be  necessary.  A  state  of  profound  anaesthesia  will 
generally  be  necessary,  though  with  intelligent  patients  I  have  often 
taken  advantage  of  the  primary  anaesthetic  state  which  ether  produces 
for  opening  abscesses,  dividing  fistulae,  and  cutting  ofiE  external  hsemor- 
rhoida. 

Accidents  are  not  common  in  operations  about  the  rectum,  but  there 
is  one  for  which  the  surgeon  siiould  always  be  prepared — haemorrhage. 
For  this  reason  a  bottle  of  dry  persulphate  of  iron,  and  a  Paquelin's 
thermo-cautery  should  always  be  at  hand.  The  thermo-cautery  as  now 
made,  Fig.  2G,  is  not  at  all  cumbersome,  and  is  exceedingly  useful  in 
many  operations  about  the  rectum.  The  bulb  containing  the  sponge  for 
the  benzine  should  never  be  filled  with  an  excess  of  fluid  which  m:iy  run 
down  into  the  point  and  interfere  with  the  working  of  the  instrument; 


Fio.  96.— Paquelin'a  thermocautery. 

and  the  platinum  point  should  be  thoroughly  heated  before  the  assistant 
begins  to  use  the  bulb  to  drive  the  air  over  the  sponge.  If  proper  regard 
be  paid  to  these  points  the  instrument  is  a  most  reliable  one,  and  in  every 
case  where  hemorrhage  is  to  be  apprehended  it  should  be  ready  for  use, 
and  an  alcohol  lamp  or  gas  jet  should  be  ready  to  heat  the  point — which 
is  sometimes  forgotten. 

A  haemorrhage  seldom  occurs  from  the  rectum  after  a  surgical  opera- 
tion— so  seldom  jis  to  be  almost  unknown — which  cannot  be  controlled 
by  the  cautery  or  by  packing  the  rectum.  The  rectum  may  be  packed 
with  either  sponges  or  lint,  and  these  may  be  used  either  with  or  without 
the  persulphate  of  iron.  !Most  cases  of  bleeding  may,  however,  be  con- 
trolled by  the  use  of  simple  ice-water  and  a  moderate  amount  of  pres- 
sure projx;rly  applied  to  the  bleeding  surface  without  the  necessity  for  a 
systematic  packing  of  the  whole  rectal  cavity.  It  is  not  long  since  I  was 
called  in  the  middle  of  the  night  to  stop  the  bleeding  from  an  incision 
which  I  had  made  into  an  abscess  of  the  ischio-rectal  fossa  about  eight 
hours  before.     I  found,  as  is  too  often  the  case,  that  the  patient  was 


64  DISEASES    OF   THE    BECTUM    AND    ANUS. 

thorouglily  immersed  iu  a  mixture  of  blood  and  persulphate  of  iron  which 
covered  him  from  the  pubes  to  the  middle  of  the  back  and  had  thor- 
oughly permeated  the  bed.  On  entering  the  room  I  was  informed  that 
the  wound  had  been  carefully  stuffed  with  lint  and  persulphate  of  iron 
*' several  times,"  and  that  the  case  was  undoubtedly  one  of  the  haemor- 
rhagic  diathesis.  A  case  like  this  is  easily  managed.  The  treatment 
consists  first  of  all  in  providing  a  good  light,  next  in  cleaning  up  the 
general  nastiness,  then  in  finding  the  bleeding  point  and  making  pres- 
sure upon  it.  In  this  case  the  bleeding  came  from  a  small  spouting 
cutaneous  vessel  and  was  at  once  controlled  by  filling  the  incision  I  had 
made  with  picked  lint  thoroughly  pressed  home  into  the  wound.  Most 
cases  of  bleeding  may  be  controlled  in  the  same  way,  but  where  the 
haemorrhage  is  within  the  bowel  it  is  not  always  easy  to  make  pressure 
upon  the  right  point  without  packing  the  entire  rectal  cavity.  For 
this  purpose  Allmgham'  recommends  the  following  procedure  which  is 
equally  simple  and  effectual. 

Take  a  medium-sized  bell-shaped  sponge  and  pass  a  strong  double 
ligature  through  the  apex  from  within  outwards  and  back  again  so  as  to 
include  a  considerable  part  of  the  sponge  in  the  bite  of  the  ligature — 
enough  so  thai  when  the  cord  is  pulled  upon  strongly  from  below  it  will 
not  tear  out.  After  wetting  the  sponge  and  squeezing  it  out  it  should 
be  powdered  with  the  persulphate  of  iron  and  passed  as  far  up  the  rectum 
as  possible  with  the  aid  of  a  rectal  bougie,  the  apex  being  upwards.  The 
whole  of  the  rectum  below  the  sponge  should  then  be  carefully  filled 
with  pledgets  of  cotton-wool  powdered  over  with  the  iron,  each  roll  being 
carefully  and  firmly  packed  away.  An  exceedingly  large  quantity  of 
cotton  may  be  crowded  into  the  rectum  in  this  way,  and  when  the  cavity 
is  filled  the  sponge  should  be  drawn  down  by  means  of  the  string  hang- 
ing out  of  the  anus,  so  that  the  whole  mass  may  be  tightly  compressed. 
If  the  bowel  has  been  thoroughly  emptied  as  recommended,  such  a  plug 
may  be  left  in  for  a  week  or  more  without  causing  any  discomfort  and  no 
bleeding  can  occur  while  it  is  in  place.  If,  however,  it  is  intended  to 
leave  the  packing  in  for  such  a  length  of  time  it  is  better  to  pass  a  large- 
sized,  stiff  rubber  male  catheter  through  the  apex  of  the  sponge  and 
pack  the  cotton  around  it.  In  this  way  a  chance  is  given  for  wind  and 
fluid  faeces  to  escape.  By  this  simple  means,  wlien  properly  used,  any 
haemorrhage  after  an  operation  upon  the  rectum  m  ly  be  controlled. 

After  operations  upon  the  rectum  or  anus,  a  supjjository  of  one  grain 
of  opium  may  generally  be  placed  in  the  rectum  with  advantage,  and  the 
surgeon  should  always  be  provided  with  them.  The  usual  dressing  con- 
sists in  placing  a  pad  of  lint  and  a  soft  towel  over  the  anus  and  fastening 
them  in  place  with  a  T  bandage.  This  form  of  bandage  will  generally 
be  found  the  best  in  any  case  where  a  continuous  dressing  is  needed. 

'  Op.  cit.,  p.  154. 


OBNERAL    RULES    REOARDIMO    EXAMINATION,    DIAGNOSIS,    ETO.         65 

Lister's  impervious  dressing  has  been  applied  to  wounds  of  the  rec- 
tum in  some  of  the  more  extensive  oijcrations,  such  as  excision  of  cancer, 
by  the  German  surgeons;  but  it  has  not  become  popular,  and  the  use  of 
free  drainage  and  plenty  of  carbolic  acid  or  some  other  disinfectant  is 
generally  considered  all  that  is  necessary  or  desirable  in  this  line.  Ver- 
ncuil  recommends  the  free  use  of  a  solution  of  chloral  as  an  antiseptic 
for  this  part. 

Wounds  of  the  rectum  will  always  heal  more  kindly  when  the  patient 
is  in  the  horizontal  position  than  when  standing  or  walking,  there  being 
less  tendency  to  venous  congestion  in  the  former  case.  Almost  any  op- 
eration may  result  in  a  sluggish  open  sore  if  the  patient  be  allowed  to 
disregard  this  rule. 

Retention  of  urine  is  of  frequent  occurrence  after  operations  upon 
these  parts,  both  in  men  and  women,  and  it  should  always  be  in  the 
mind  of  the  surgeon.  It  is  not  generally  of  long  duration,  and  it  may 
often  be  overcome  by  a  bath  and  hot  applications,  without  having  recourse 
to  the  catheter.  The  following  case  conveys  a  lesson  in  this  matter 
which  should  never  be  forgotten. 

Case  II. — I  was  requested  several  years  ago  by  a  gentlemen  to  make 
an  autopsy  on  his  brother,  who  had  died  very  suddenly  and  unexpectedly 
after  being  confined  to  his  bed  about  a  week  with  an  abscess  near  the 
anus.  Before  the  abscess  appeared  the  man  had  been  in  perfect  health, 
and  was  apparently  doing  well  up  to  the  moment  of  his  death,  as  the  ab- 
scess had  been  opened  on  the  day  before,  with  great  relief  to  pain,  and 
was  discharging  freely.  I  made  the  autopsy,  as  requested,  and  found  a 
bladder  distended  to  the  point  of  rupture,  the  urine  dammed  back  upon 
the  kidneys,  which  were  gorged  with  blood,  and  the  cerebral  vessels 
greatly  congested.  The  man  had  died  very  suddenly  in  a  convulsion.  A 
little  questioning  revealed  the  fact  that  from  the  first  day  of  the  disease 
there  had  been  retention  of  urine  with  dribbling  from  the  overflow;  and 
that  for  the  pain  arising  from  this  condition  opium  had  been  freely  given 
tip  to  the  day  of  death. 

Once  during  his  sickness  an  old  woman  in  the  house  had  applied  a 
hot  flannel  cloth  over  the  bowels,  and  the  patient  had  passed  an  immense 
amount  of  urine.  The  condition  of  the  bladder  seemed  to  have  entirely 
escaped  the  notice  of  his  medical  attendant,  as  it  probably  has  escaped 
the  attention  of  most  surgeons  at  some  time,  though,  fortunately,  with- 
out, as  in  this  case,  a  fatal  result. 


66  DISEASES   OB"   THE    BECTDM    AND    ANUS. 


CHAPTEE    IT. 

INFLAMMATION   OF   THE    RECTUM. 

Cases  of  Proctitis. — Varieties  :  Acute,  Chronic,  Primary,  Secondary,  Localized, 
Greneral. — Symptoms  and  Course  of  each  Variety. — Causes  of  Proctitis  : 
Direct  Propagation,  Foreign  Bodies,  Drastic  Cathartics,  Gout,  Pederasty, 
Gonorrhoea.  — Treatment. 

The  two  cases  which  follow  are  not  only  interesting  from  their  rarity, 
but  as  being  good  examples  of  two  different  stages  of  the  affection  under 
consideration. 

Case  III, — Mrs.  G.,  age  thirty-seven,  mother  of  three  children.  The 
patient,  a  delicate  and  rather  anasmic  lady,  had  not  been  in  good  health 
for  some  time  past,  but  had  never  had  any  trouble  with  the  rectum  until 
one  month  before  consulting  me.  At  that  time  she  was  surprised  to  find 
that  she  had  passed  a  considerable  quantity  of  blood  while  at  stool,  and 
this  haemorrhage  had  been  repeated  at  intervals  of  about  a  week  up  to  the 
day  before  my  visit.  There  had  never  been  any  pain  in  the  rectum  or 
anus,  or  any  signs  of  haemorrhoids,  and  a  careful  examination  failed  to 
reveal  any  source  of  the  haemorrhage.  The  lady  complained,  however,  of 
a  good  deal  of  discomfort  in  the  back  and  pelvis;  had  missed  her  last 
menstrual  period,  and  was  decidedly  constipated.  An  examination 
showed  a  uterus  enlarged  and  retro  verted,  hnd.  a  considerable  mass  of 
faeces  in  the  sigmoid  flexure  and  descending  colon,  and  treatment  was 
begun  for  these  conditions.  The  bowels  were  unloaded  of  many  scyba- 
lous masses  by  means  of  frequent  enemata;  and  the  uterine  condition  was 
so  far  improved  by  treatment  that  the  menses  soon  reappeared,  and  the 
pain  and  discomfort  passed  away.  The  bleeding  from  the  rectum  never 
recurred,  nor  has  the  patient  ever  again  had  her  attention  called  to  thafr 
part  up  to  the  present  time — four  years  later. 

The  diagnosis  in  this  case  was  a  simple  congestion  of  the  rectal 
mucous  membrane,  brought  about  by  the  retained  faeces  and  by  the  uterine 
disorder,  relieving  itself  by  a  discharge  of  blood  from  the  over-distended 
veins.  Had  the  conditions  remained,  other  symptoms  would  in  all  prob- 
ability have  soon  developed,  such  as  heat  and  tension  at  the  anus,  possi- 
bly a  slight  mucous  discharge,  pruritus  ani,  and,  finally,  hemorrhoids. 
There  are  various  other  causes  of  such  a  condition,  besides  impacted 
faeces  or  menstrual  disorders,  such,  for  example,  as  excess  at  table,  pro- 


INFLAMMATION    OF    THE    RBOTUM.  67 

longed  horse-back  exercise  or  carrijige  riding,  pregnancy,  drastic  purga- 
tives, and,  in  short,  anything  which  tends  to  produce  hyperaemia  of  the 
pelvic  viscera. 

In  most  cases  of  bleeding  from  the  rectum  a  diagnosis  of  congestion 
alone  would  bo  an  error;  for  a  congestion  sufficiently  marked  to  cause 
haemorrhage  is  rare,  and  bleeding  is  in  most  cases  a  symptom  either  of 
hwmorrhoids,  polypus,  or  some  more  serious  affection.  But  in  this  case 
there  was  no  such  cause,  and  the  subsequent  history  of  four  years  with  no 
other  rectal  symptoms  tends  to  strongly  confirm  the  diagnosis. 

Note. — While  speaking  of  hjeraorrhage  from  the  rectum,  it  may  be  well  to  re- 
fer to  two  cases  of  bleeding  which  have  recently  been  reported  in  the  New  York 
Medical  Record.  The  first  (N.  Y.  Med.  Record,  Sept.  27th,  1879)  is  by  Dr.  Manley, 
of  Lawrence,  Mass.  It  occurred  in  an  app>arently  healthy  infant  three  days  old, 
and  ended  fatally.  A  post-mortem  examination  showed  that  the  blood  came  from 
an  opening  in  one  of  the  rectal  veins  about  three  incbee  from  the  anus,  which  ad- 
mitted of  the  introduction  of  a  bristle. 

The  second  case  (N.  Y.  Med.  Record,  Jan.  17th,  1880)  is  reported  by  Dr. 
McGuire,  of  Salem,  Ohio,  and  is  very  similar,  the  child  being  about  the  same  age. 
Notwithstanding  suitable  treatment  by  styptic  applications,  this  also  terminated 
fatally;  but  no  autopsy  was  obtained,  and  the  precise  source  of  the  haemorrhage 
is  unknown. 

The  second  case  is  one  in  which  congestion  had  ended  in  actual  in- 
flammation or  proctitis. 

Case  IV. — Woman,  married,  age  twenty-three,  mother  of  two  chil- 
dren: youRgest  six  months  old.  Patient  has  always  been  constipated, 
and  for  years  has  been  in  the  habit  of  using  purgatives  whenever  she 
desired  an  evacuation.  For  the  past  six  months  has  noticed  occasional 
discharge  of  blood  and  slime  from  the  rectum  which  is  constantly  in- 
creasing. Now  suffers  great  pain  on  defecation,  and  the  amount  of  blood 
and  muco-purulent  matter  is  increasing  so  that  while  at  first  it  only 
came  away  when  at  stool,  it  now  comes  several  times  a  day.  With  this 
she  has  much  pain  in  the  rectum  at  all  times,  and  is  in  poor  general  con- 
dition, having  lost  her  appetite,  and  being  unable  to  sleep. 

A  careful  examination  of  the  rectum  showed  it  to  be  congested,  hot, 
and  painful  as  far  as  the  eye  could  see;  but  notliing  else  was  apparent. 
The  amount  of  discharge  suggested  the  idea  of  a  gonorrhoea  of  the  rec- 
tum, but  there  was  no  inflammation  of  the  vagina,  and  careful  question- 
ing of  the  patient  left  no  room  for  such  a  suspicion.  The  cause  of  the 
trouble  in  tliis  case  also  was  not  difficult  to  find,  the  patient  having  been 
in  the  habit  of  taking  large  doses  of  patent  cathartic  remedies  two  or 
three  times  a  week  for  a  long  time;  and  as  the  trouble  developed  imme- 
diately after  her  last  confinement,  this  may  not  have  been  without  its 
influence  as  an  exciting  cause. 

This  case  gives  a  very  good  idea  of  the  clinical  liistory  of  acute  inflamma- 
lion  of  the  rectum.  A  proctitis  may  be  either  acute  or  chronic,  primary 
or  secondary,  localized  or  general.     The  localized   variety  is  generally 


68  DISEASES    OF   THE    EEOTUM    AND    AND8. 

due  to  the  injury  inflicted  by  a  foreign  body  or  to  some  irritation  acting 
upon  a  small  part  of  the  rectal  surface.  In  the  acute  form  the  inflamma- 
tion does  not  extend  deeper  than  the  mucous  membrane  which  is  con- 
gested and  hyperjemic.  In  the  chronic,  the  inflammation  involves  the 
submucous  and  muscular  layers.  The  acute  generally  ends  in  resolution 
in  from  eight  to  fourteen  days  where  the  cause  can  be  found  and  removed. 
It  may,  however,  in  severe  cases  go  on  to  actual  gangrene  and  terminate 
fatally.  The  chronic  results  in  infiltration  and  consequent  thickening 
of  the  rectal  wall,  and  may  end  in  ulceration,  either  superficial  and 
confined  to  the  epithelial  layer  of  the  mucous  membrane,  or  deep  and 
involving  the  whole  thickness  of  the  mucous  layer.  "What  is  described 
a  follicular  ulceration  (ulceration  affecting  the  mouths  of  the  tubular 
follicles)  may  result  from  chronic  inflammation;  and  these  ulcers,  which 
are  very  minute  at  first,  may  coalesce  and  gain  in  depth  till  they  cause 
perforation  of  the  bowel.  When  the  perforation  is  above  the  peritoneal 
reflection  a  fatal  peritonitis  may  result;  when  lower  down,  an  abcess 
or  fistula  (see  Fistula).  A  chronic  proctitis  may  in  this  way  be  a  cause 
of  stricture,  and  may  result  in  the  hypertrophy  known  as  chronic  paren- 
chymatous proctitis.' 

The  symptoms  of  this  affection  have  been  partially  detailed  in  the  two 
cases  which  have  been  related.  They  are,  in  the  acute  form,  a  sensation 
of  heat  and  weight  in  the  part  which  may  amount  to  actual  pain,  and 
may  involve  the  bladder,  uterus,  and  sacral  region,  and  radiate  into  the 
loins  and  down  the  thighs.  The  anus  also  becomes  painful,  red  and 
contracted,  and  in  children  the  mucous  membrane  may  become  slightly 
everted  from  the  swelling  and  tenesmus.  The  evacuations  soon  become 
painful  and  increased  in  number  and  the  faeces  are  streaked  with  mucus, 
blood,  and  pus.  There  is  apt  to  be  also  a  train  of  symptoms  referable 
to  the  bladder,  and  to  the  generative  organs,  such  as  painful  micturition, 
cystitis,  and  leucorrhoea. 

With  these  local  symptoms  there  may  be,  as  in  the  case  reported, 
more  or  less  constitutional  disturbance,  fever,  and  loss  of  appetite.  As 
the  discharge  from  the  inflamed  surface  increases  in  amount,  the  desire 
to  empty  the  rectum  produces  more  frequent  evacuations,  so  that  while 
at  first  the  faeces  only  are  stained  with  pus  and  blood,  later  the  evacua- 
tions consist  entirely  of  the  muco-purulent  matter,  and  the  anus  may 
become  excoriated  by  the  discharge. 

In  the  chronic  form  the  symptoms  are  all  less  marked.  The  diarrhoea 
may  alternate  with  constipation,  and  the  discharge  will  occur  only  at 
the  time  of  defecation.  This  condition  may  last  for  years.  An  examina- 
tion of  the  rectum  during  the  acute  stage  of  proctitis  will  generally 
cause  considerable  pain.  The  rectal  mucous  membrane  will  be  found 
intensely  congested,  and  the  temperature,  as  shown  by  the  thermometer 

'  Diet.  Encyc.  des  Sci.  Med.,  Art.  Rectum. 


INFLAMMATION    OF   THE    RECTUM.  69 

or  even  by  the  finger,  will  be  increased.  In  the  chronic  stage,  the  solitary 
glands  may  occasionally  be  recognized  as  small  round  prominences  in 
the  substance  of  the  mucous  membrane. 

Proctitis  is  generally  found  associated  with  stricture  of  the  rectum 
and  is  secondary  to  it.  In  these  cases  the  mucous  membrane  below  the 
stricture  will  be  found  congested  and  covered  with  pus  or  bloody  mucus, 
while  above  it' is  eroded  and  destroyed;  sometimes  only  superficially,  at 
others  for  its  entire  depth.  In  such  cases  the  other  layers  will  be  found 
hypertrophied,  especially  the  circular  muscular  layer.' 

The  causes  which  may  produce  proctitis  are  numerous.  It  may  re- 
sult by  direct  propagation  and  continuity  of  surface  from  inflamed 
haemorrhoids  or  prolapsus;  or  from  any  erosion  about  the  anus  such  as  a 
mucous  patch  or  eczema.  It  may  be,  and  often  is  caused  by  the  presence 
of  foreign  bodies  or  of  hardened  faeces  and  indigestible  remains  of  food 
which  act  as  foreign  bodies;  and  by  irritating  suppositories,  injections, 
or  medicinal  applications.  As  in  the  case  given  above,  it  may  be  caused 
by  the  abuse  of  drastic  purgatives  such  as  aloes,  gamboge,  or  even  rhubarb 
in  excess.  It  has  been  seen  to  result  from  prolonged  sitting  upon  a  cold 
or  wet  seat,  and  when  found  in  children  it  will  generally  be  due  to  the 
presence  of  worms.  It  may  be  a  symptom  of  gout  (Esmarch,  Bushe) 
alternating  with  the  manifestation  of  the  disease  in  its  usual  seat,  and 
there  maybe  a  true  diphtheria  of  the  rectum, as  there  may  be  of  the  va- 
gina, and  the  formation  of  a  membrane  similar  to  that  seen  in  the  throat. 
Again  the  disease  may  result  both  in  men  and  women  from  the  habit  of 
passive  pederasty,  and  in  such  cases  may  be  due  either  to  mechanical 
violence  or  to  the  inoculation  with  gonorrhceal  pus.  A  true  gonorrhoea 
of  the  rectum,  whether  caused  in  this  way  or  by  direct  inoculation  in 
women  by  pus  which  is  passing  over  the  anus  from  the  vagina,  is  very 
rare.  Tardieu*  has  never  observed  a  single  case.  Gosselin*  saw  only 
one  case  at  Lourcine  in  three  years.  Eollet*  reports  a  case  caused  by 
direct  inoculation  from  the  penis  to  the  rectum  in  a  patient  who  was  in 
the  habit  of  using  a  finger  in  the  anus  to  provoke  a  passage.  A.  Bon- 
niere'  found  it  very  difficult  to  inoculate  the  rectal  mucous  membrane 
with  gonorrhceal  pus  placed  upon  it  through  a  tube,  though  the  anus 
was  easily  affected.  On  the  other  hand,  Requin'  believes  it  almost  sure  to 
follow  passive  pederasty  with  a  person  suffering  from  gonorrhcea.  The 
diagnosis  of  gonorrhceal  proctitis  will  rest  upon  the  amount  and  puru- 
lent character  of  the  discharge,  and  upon  the  existence  of  gonorrlioea 

'  Diet.  Encyc.  des  Sci.  Med.,  Art.  Rectum. 

*  Etudes  Medico-Iegales  sur  les  Attentats  aux  Mceurs,  4th  ed.,  1862,  p.  179. 
•'Arch.  Genl.  de  Med.,  1854. 
■*  Diet.  Enc.  des  Sei.  Med.,  Art.  Rectum. 

'  Recherches   Nouvelles  sur  la   Blenuorrhagie,  Arch.    Genl.    de  Med.,  Apr^ 
1874. 

♦Elements  de  Path.  Med.  Rectito,  t.  i.,  p.  729. 


70  '  DISEASES    OF    THE    KECTUM    AND   ANUS. 

of  the  vagina  in  women;  or  the  confession  of  intercourse  with  a  diseased 
person,  in  men. 

The  treatment  of  proctitis  consists  first  of  all  in  an  endeavor  to  discover 
and  remove  the  cause  of  the  congestion,  be  it  what  it  may.  In  the  acute 
stage,  the  pain  and  tenesmus  may  be  overcome  by  warm  baths,  and  anodyne 
injections  of  starch-water  with  a  few  drops  of  laudanum.  The  bowels 
should  be  kept  open  by  laxatives  such  as  castor  oil  or  preferably  the  saline 
cathartics  in  small  doses.  The  patient  should  also  be  confined  to  the 
bed,  and  placed  upon  a  diet  chiefly  of  milk.  In  the  chronic  stage,  astrin- 
gents are  indicated;  such  as  alum  and  tannin,  and  to  these  may  be  added 
suppositories  of  iodoform  (gr.  v.),  and  the  same  rules  with  regard  to  rest 
and  diet  should  be  observed. 


A.BOE88    AND   FISTULA.  71 


CHAPTER   Y. 

ABSCESS   AND   FISTULA. 

Abscess  divided  into  Superficial  and  Deep. — Superficial  Abscesses. — Simple  Fu- 
runcles; Causes;  Characters;  Results;  Treatment, — Suppuration  of  External 
Hsemorrhoid. — Suppuration  of  Internal  Haemorrhoid. — Diffuse  Inflammation 
of  Subcutaneous  Tissue,  Causes;  Symptoms;  Treatment. — Form  of  Incision. 
— Deep  Abscesses. — Divided  into  Abscess  of  the  Ischio-Rectal  Fossa  and  of 
the  Superior  Pelvi-Rectal  Space. — Causes;  Symptoms;  Diagnosis. — Dangers 
of  Deep  Abscess. — Formation  of  Deep  and  Extensive  Fistulas. — Horse-shoe 
Abscess. — Idiopathic  Gangrenous  Cellulitis. — Reasons  why  Abscesses  do  not 
Heal  Spontaneously. — Prognosis. — Treatment. — Incisions  and  Subsequent 
Treatment  of  Deep  Abscesses.  —  Incontinence  of  Faeces.  —  Relief  of  In- 
continence resulting  from  Operation. — Fistula. — Generally  due  to  Abscess. 
—  Divided  into  Superficial  and  Deep.  —  Complete  Fistula.  —  External 
Fistula.  —  Internal  Fistula.  —  Description  of  Superficial  Fistulas. — How  to 
Detect  an  Internal  Opening.  —  Location  of  Internal  Opening.  —  Descrip- 
tion of  Track  of  Fistula. — Symptoms  of  Superficial  Fistula.  — Deep  Fis- 
tula.— Fistula  with  Numerous  External  Openings. — Blind  Internal  Fistula. 
— Ulceration  of  Rectum  Causing  Internal  Fistula. — Treatment. — Spontaneous 
Cure. — Advisability  of  Operation. — Fistula  in  Relation  to  Phthisis. — Contra- 
indications to  Operation. — Treatment  by  Cauterization. — The  Ligature. — The 
Elastic  Ligature. — Galvano-Cautery. — How  to  Pass  Ligature. — Incision. 
— Description  of  Operation. — Author's  Knife  for  Fistula. — Division  of  Deep 
Tracks. — Treatment  of  Track  running  up  the  Bowel. — Treatment  of  Blind 
External  Variety;  of  Horse-shoe  Variety;  of  Fistula  with  Numerous  Exter- 
nal Openings. — Dressing  after  Incision. — Packing  the  Incision. — Haemorrhage 
in  Operation. — Treatment  of  Blind  Internal  Variety. — Incurable  FistuUe. — 
Treatment  of  Deep  and  Extensive  Tracks. — Fistula  with  Stricture. 

Abscesses  in  the  region  of  the  anus  and  rectum  are  best  classified 
according  to  their  anatomical  location  into  superficial  and  deep.  Of 
€ach  of  these  there  are  several  different  Tarieties. 

Considering  first  the  superficial  variety,  the  simplest  form  will  be 
found  to  be  that  which  involves  the  skin  of  the  margin  of  the  anus  alone, 
and  which  generally  originates  in  one  of  the  minute  glands  of  the  part. 
Such  an  abscess  or  furuncle,  for  it  is  really  only  a  furuncle,  may  be  due  to 
traumatism,  or  to  any  irritation,  such  as  the  use  of  improper  paper  after 
defecation,  prolonged  walking  or  horse-back  riding,  a  menstrual  dis- 
charge, or  a  discharge  due  to  diarrhcea  or  dysentery. 

This  form  of  disease  is  always  distinctly  circumscribed,  is  generally 


72  'DISEASES    OF   THE    RECTUM    AND    ANUS. 

about  the  size  of  an  almond,  is  found  by  preference  in  robust  persons^ 
more  often  in  men  than  in  women,  seldom  in  old  people,  and  almost 
never  in  children.  It  generally  goes  on  rapidly  to  suppuration,  breaks 
spontaneously  on  the  cutaneous  surface,,  and  heals  without  the  formation 
of  fistula,  though  in  cachectic  or  phthisical  patients  it  may  pursue  a 
contrary  course,  the  skin  over  it  becoming  thin  and  violet  colored,  and 
finally  rupturing,  leaving  a  permanent  subcutaneous  fistula. 

The  treatment  of  such  an  abscess  consists  chiefly  in  the  attempt  to 
avoid  the  formation  of  a  fistula,  and  the  best  means  for  accomplishing 
this  end  is  an  early  incision  as  soon  as  suppuration  appears  inevitable. 
Resolution  is  hardly  to  be  expected,  but  it  may  be  sought  for  by  the  use 
of  laxatives,  rest  in  the  horizontal  posture,  and  the  application  of  a  blad- 
der of  ice.  The  incision  should  be  large  enough  to  allow  of  the  free 
exit  of  pus,  and  after  it  has  been  made,  the  part  may  be  poulticed  for  a 
day  or  two,  and  the  abscess  cavity  then  dressed  with  lint,  care  being 
taken  to  keep  the  lips  of  the  incision  separated. 

Another  frequent  cause  of  superficial  abscess  is  the  acute  inflamma- 
tion and  suppuration  of  an  external  haemorrhoid,  which  generally  comes 
on  after  an  attack  of  constipation  and  straining  at  stool,  or  may  be  due  to 
the  same  causes  as  the  last.  The  suffering  caused  by  such  a  condition, 
as  by  the  one  last  described,  is  out  of  all  proportion  to  its  apparent  im- 
portance, and  is  sufficient  to  incapacitate  a  person  of  sensitive  organi- 
zation from  all  accustomed  duties.  The  remains  of  former  external 
haemorrhoids  are  always  liable  to  this  accident,  and  by  the  proper  abor- 
tive treatment,  the  inflammation  may  sometimes  be  overcome  without 
suppuration.  If,  however,  suppuration  appears  to  be  inevitable,  a  small 
sharp-pointed  bistoury  should  be  quickly  passed  through  the  little 
tumor. 

There  is  also  a  form  of  superficial  abscess  which  lies  nearer  to  the 
mucous  membrane  than  the  skin,  and  is  due  to  the  acute  inflammation 
of  an  internal  haemorrhoid,  either  just  at  the  verge  of  the  anus  or  within 
the  sphincter.  This  is  in  reality  a  circumscribed  phlebitis  in  a  venous 
pouch  which  is  shut  off  from  the  general  circulation.  A  circumscribed, 
tense,  exquisitely  painfultumor  is  formed,  varying  in  size  from  a  gi*ape 
to  an  almond,  which,  after  a  few  days  of  suffering,  ruptures  spontane- 
ously, and  allows  the  escape  of  a  small  quantity  of  pus.  Such  an  abscess, 
when  within  the  bowel,  is  always  liable,  as  will  be  shown  later,  to  result 
in  the  formation  of  a  blind  internal  fistula  if  left  to  its  own  course,  and 
should,  therefore,  be  treated  by  early  incision. 

There  is  still  another  variety  of  superficial  abscess,  more  serious  in 
its  consequences  than  those  already  described,  for  the  reason  that  it 
affects  the  subcutaneous  tissue  and  not  the  skin,  and  is  diffuse  and  not 
circumscribed.  The  causes  of  this  variety  of  abscess  are  the  same  as  of 
those  already  mentioned,  though  traumatism  plays,  perhaps,  a  moro 
important  role.     Falls,  kicks,  horse-back  exercise,  and  violence  in  the 


ABSCESS    AMD   FISTULA.  73 

use  of  the  syringe  are  its  most  frequent  antecedents.  Surgical  inter- 
ference with  the  rectum,  as  in  the  removal  of  a  hjEmorrhoid,  may  also  be 
followed  by  this  form  of  abscess,  and  it  may  arise  from  the  perforation 
of  the  wall  of  the  bowel  just  above  the  sphincter,  by  an  ulceration  of  any 
kind,  generally,  however,  that  due  to  a  foreign  body.  It  has  also  been 
known  to  follow  the  suppuration  of  an  internal  haemorrhoid. 

The  symptoms  of  this  form  of  disease  vary  greatly  in  different  cases. 
In  caciiectic  persons,  pus  may  form  in  large  quantity,  aad  break  into  the 
bowel  without  the  knowledge  of  the  patient,  and  a  blind  internal  fistula 
may  result.  The  diagnosis  is  generally  easy.  There  will  be  the  usual 
pain,  tenderness,  and  swelling;  and  if  the  pain  bo  not  too  severe  to 
admit  of  the  attempt,  fluctuation  may  be  obtained  by  introducing  one 
finger  into  the  rectum,  and  making  counter-pressure  with  the  other  hand 
outside. 

There  is  little  use  in  hoping  for  resolution  in  an  abscess  of  this  kind, 
and  all  active  attempts  to  cause  it  will  be  found  to  do  harm,  rather  than 
good.  The  proper  treatment  is  an  early  free  incision.  If  the  incision 
be  made  early,  it  may  in  itself  have  an  abortive  action,  and  under  such 
circumstances  it  need  not  be  very  large.  If  pus  has  already  formed,  or 
the  skin  has  begun  to  grow  thin  over  the  abscess  cavity,  the  incision 
should  be  free  enough  to  allow  of  the  easy  escape  of  the  contents,  for  in 
this  way  only  can  the  formation  of  a  fistula  be  avoided.  In  such  a  case, 
drainage  should  be  resorted  to  after  the  incision,  and  every  effort  should 
be  made  to  secure  healing  from  tlie  bottom  of  the  cavity. 

When  the  incision  is  matle  in  the  early  stage  of  such  a  tumor  as  this, 
while  the  skin  is  yet  hard  and  infiltrated,  a  free  haemorrhage  from 
cutaneous  vessels  is  not  uncommon,  nor  on  account  of  its  antiphlogistic 
action  is  it  to  be  deprecated.  Only  when  it  has  passed  the  bounds  of 
safety  need  any  steps  be  taken  to  aiTCst  it,  and  this  may  always  bo  done 
by  a  careful  stuffing  of  the  incision  with  picked  lint.  A  word  of  caution 
against  opening  such  abscesses  as  these  in  the  surgeon's  office,  and  allow- 
ing the  patient  to  walk  home,  may  not  be  out  of  place;  for  a  small  artery 
may  commence  spurting  at  any  moment  during  the  active  exercise. 

Deep  Abscess. — The  deep  abscesses  of  this  region  differ  greatly  from 
those  already  described,  in  their  location,  extent,  and  gravity.  They 
may  with  advantage  be  divided  into  those  of  the  ischio-rectal  fossa  and 
those  of  the  superior  pelvi-rectal  space. ' 

An  abscess  of  the  ischio-rectal  fossa  is  generally  bounded  by  the 
levator  ani  muscle  superiorly,  and  by  the  skin  below,  with  the  rectum  on 
one  side,  and  the  adjacent  portion  of  the  pelvis  on  the  other.  An 
abscess  of  the  superior  pelvi-rectal  space,  on  the  other  hand,  originates 
in  the  lax  connective  tissue  around  tiie  upper  portion  of  the  rectum 
above  the  levator  ani  muscle.     It  may  assume  vast  proportions,  blending 

'  Richet:  Traite  d'Anat.  Med.  Chir. 


74:  .     DISEASES   OF   THE    KECTUM    AND    ANUS. 

laterally  with  the  subperitoneal  connective  tissue  of  the  iliac  fossa,  and 
burrowing  in  almost  any  direction  in  the  true  pelvis. 

The  causes  of  deep  rectal  abscesses  are  various.  Traumatism  is  per- 
haps the  most  frequent,  and  the  injury  is  generally  internal,  rather  than 
external,  and  is  caused  by  the  point  of  a  syringe  or  a  foreign  body, 
rather  than  by  kicks  and  falls.  Foreign  bodies,  such  as  fish-bones,  may 
pass  entirely  through  the  rectal  wall,  and  be  found  loose  in  the  cavity  of 
the  abscess  they  have  caused.  Such  an  abscess  may  also  be  due  to  the 
injury  inflicted  by  the  foetal  head  in  parturition,  and  in  such  a  case,  the 
diagnosis  may  be  difficult  to  make  from  a  puerperal  inflammation,  due 
to  blood  poisoning  and  involvement  of  the  lymphatics.  They  may  also 
be  secondary  to  diseases  of  the  urinary  organs,  such  as  acute  inflamma- 
tion of  the  prostate,  or  a  rupture  of  the  urethra,  and  extravasation  of 
urine;  and  they  may  result  from  rupture,  ulceration,  or  perforation  of 
the  rectal  wall,  m  connection  with  stricture. 

This  explains  partly,  though  not  completely,  the  frequent  coexistence  of 
stricture  and  numerous  fistulae;  for  a  stricture  may  act  as  the  exciting 
cause  of  a  deep  abscess  by  the  impairment  of  vitality  and  nutrition 
which  it  causes,  as  well  as  by  producing  a  perforating  ulcer  above,  as  is 
proven  by  the  fact  that  a  great  many  fistulae  have  their  internal  openings 
below,  and  not  above  the  constriction. 

Again,  these  abscesses  may  be  due  to  a  submucous  inflammation,  and 
production  of  pus,  which  first  breaks  into  the  rectum,  and  forms  an 
internal  fistula,  and  subsequently  extends  outwards,  forming  a  large 
abscess;  or  they  may  be  due  to  an  acute  phlebitis,  or  to  faulty  nutrition 
and  a  generally  vitiated  state.  Finally,  they  may  be  in  their  origin 
entirely  disconnected  with  the  rectum,  and  due  to  disease  of  some 
neighboring  part,  or  to  necrosis  of  some  adjacent  bone  of  the  pelvis  or 
spine. 

Symptoms. — In  an  abscess  of  the  superior  pelvi-rectal  space  the  symp- 
toms are  often  obscure  and  far  from  characteristic.  There  is  more  or  less 
yague  pain  in  the  pelvis  and  lumbar  region,  which  is  seldom  intense  and 
is  generally  increased  in  defecation.  Fever  may  be  entirely  absent,  is  sel- 
dom continuous,  and  chills  are  only  occasionally  met  with  when  pus  is 
formed.     In  addition  there  is  more  or  less  headache  and  general  malaise. 

An  abscess  of  the  ischio-rectal  fossa  may  at  its  commencement  be  ac- 
companied by  the  same  symptoms,  but,  later,  the  skin  becomes  hard,  red, 
and  oedematous  sometimes  over  a  large  portion  of  the  corresponding  but- 
tock, the  pam  is  very  severe,  and  rectal  touch  impossible.  The  general 
symptoms  are  those  of  any  acute  inflammation.  In  abscess  of  the  superior 
pelvi-rectal  space,  when  the  disease  has  extended  to  the  cellular  tissue  of 
the  iliac  fossa,  immense  collections  of  pus  may  form,  and  this  may  burrow 
in  any  direction.  In  men  it  generally  follows  the  course  of  the  bowel,  in- 
volves secondarily  the  ischio-rectal  fossa,  and  makes  its  way  through  the 
skin  at  some  distance  from  the  anus.     In  women  it  is  more  apt  to  pursue 


ABSCESS    AND   FISTULA.  75 

a  contrary  direction  and  may  appear  on  the  surface  in  the  region  of  the 
crest  of  the  ilium  or  in  the  groin.  An  abscess  of  the  ischio-rectal  fossa 
may  tend  to  discharge  its  contents  upwards  toward  the  superior  perineal 
region,  being  less  confined  by  fascia  and  muscle  in  this  direction.  In 
this  way  the  prostate  and  urethra  may  be  implicated,  and  the  signs  of  re- 
tention of  urine  may  be  joined  with  those  which  point  more  directly  to  the 
rectum. 

The  pus  from  such  an  abscess,  in  time,  generally  breaks  on  the  cuta- 
neous surface  and  forms  one  or  several  permanent  fistulous  tracks.  The 
pus  from  a  pelvi-rectal  abscess  not  infrequently  makes  its  way  into  the 
rectum  and  is  discharged  with  each  act  of  defecation ;  before  the  faeces 
when  the  opening  is  near  the  anus,  after  them  when  it  is  above  the  rectal 
pouch.  It  may,  however,  rupture  into  the  vagina,  bladder,  uterus,  or  per- 
itoneum, but  these  internal  openings  are  not  the  rule,  but  the  exception, 
for  the  pus  generally  finds  its  way  to  the  cutaneous  surface,  and  fistulaB 
result  as  with  ischio-rectal  abscesses.  Either  variety  may  cause  fistu- 
lous tracks  upwards  into  the  true  pelvis,  downwards  into  the  perineum,  or 
outwards  into  the  thigh.  When  the  jius  reaches  the  rectum  it  may  bur- 
row for  a  considerable  distance  in  the  submucous  connective  tissue  of  the 
bowel,  and  separate  the  mucous  membrane  from  its  attachment  before 
perforating  it.  In  this  way  two  large  abscess  cavities  may  be  formed 
communicating  with  each  other  by  a  narrow  orifice. 

What  is  now  generally  known  as  the  horse-shoe  abscess  or  fistula  is  due 
to  the  formation  of  an  abscess  in  each  fossa  and  the  communication  of  the 
two  behind  the  rectum  through  the  substance  of  the  sphincter  muscle  at 
its  attachment  to  the  coccyx.  Such  an  abscess  generally  has  one  opening 
into  the  bowel  and  two  on  the  cutaneous  surface,  though  the  latter  may 
be  single  also.  By  manipulation  the  pus  maybe  made  to  cross  from  one 
fossa  to  the  other  imparting  a  characteristic  sense  of  fluctuation. 

There  is  a  form  of  gangrenous  cellulitis  which  sometimes  affects  the 
ischio-rectal  region.  It  is  a  rare  disease,  and  is  generally  idiopathic. 
In  it  there  is  no  pus  formed,  but  the  cellular  tissue  and  the  skin  over  it 
become  necrosed  and  sloui^li  in  large,  black  masses.  The  adjacent  por- 
tion of  the  rectal  wall  may  be  involved  and  the  rectum  be  laid  open  for  a 
considerable  extent.  The  disease  is  attended  with  fever  and  great  pros- 
tration; the  tendency  to  relapse  and  extension  is  marked,  and  the  cavity 
left  after  separation  of  the  slough  closes  very  slowly. '  This  form  of  dis- 
ease may  be  fatal. 

The  reasons  why  abscesses  in  this  region  so  seldom  heal  spontaneously 
are  to  be  found  in  the  anatomy  of  the  part,  and  the  fixedness  or  mobility 
of  the  walls  of  the  abscess  cavitv.     In  the  ischio-rectal  varietv  the  skin  is 


'  A  Clinical  Lecture  on  Idiopathic  Gangrenous  Cellulitis  around  the  Rectum. 
Fumeaux  Jordan,  Brit.  Med.  Jour.,  Jan.  18th,  1879.  Also,  Jackson,  Brit.  Med. 
Jour.,  Feb.  8th,  1879. 


76  '  DISEASES   OF   THE   BECTUM    AND    ANUS. 

hard,  thickened  and  lardaceous;  and  from  its  rigidity  cannot  yield  its 
position  to  allow  of  healing.  The  walls  of  the  abscess  higher  up  in  the 
pelvi-rectal  space,  on  the  contrary,  move  with  the  varying  fulness  of  the 
abdominal  or  pelvic  organs  with  the  incessant  action  of  the  levator  ani, 
and  with  the  fulness  or  vacuity  of  the  abscess  cavity,  which  depends  on 
the  intermittent  discharge  of  pus  through  its  small  opening. 

Diagnosis. — The  diagnosis  of  these  conditions  should  be  made  with 
great  care,  for  on  a  correct  appreciation  of  the  extent  of  the  disease  will 
depend  the  prognosis  and  treatment;  and  this  class  of  fistulae  are  not 
always  proper  cases  for  operation. 

A  fistulous  track  communicating  with  a  pelvi-rectal  abscess  may  gene- 
rally be  recognized  by  its  length  and  by  the  amount  of  tissue  between  it 
and  the  bowel,  which  may  easily  be  estimated  with  one  finger  in  the  rec- 
tum and  a  probe  in  the  track.  The  probe  does  not  approach  the  rectum, 
but  either  runs  parallel  with  it,  or  recedes  from  it.  The  flow  of  pus  from 
the  opening  is  also  apt  to  be  intermittent  and  to  occur  at  the  time  of 
defecation,  being  caused  by  the  same  muscular  effort.  Sometimes,  when 
the  cavity  has  not  been  recently  emptied,  a  soft  tumor  may  be  felt  by 
rectal  touch,  and  pressure  upon  it  may  cause  a  flow  of  pus.  With  the 
pus  bubbles  of  gas  may  also  appear,  but  in  a  large  abscess  in  the  neighbor- 
hood of  the  bowel  this  is  not  a  proof  of  an  internal  opening,  but  may  be 
due  merely  to  the  proximity  of  the  intestine. 

Prognosis. — The  prognosis  is  necessarily  grave.  In  the  beginning 
the  patient  is  exposed  to  all  the  dangers  of  pyaemia,  peritonitis,  and 
phlebitis;  and  should  the  abscess  go  on  to  a  favorable  termination  in  an 
external  opening,  there  is  still  the  dread  that  it  may  at  any  time  seek 
another  opening  toward  the  peritoneum  with  a  fatal  result.  The  imme- 
diate results  being  favorable,  the  ultimate  ones  may  still  be  disastrous ; 
being  those  which  always  attend  upon  prolonged  suppuration — visceral 
complications,  amyloid  degeneration  of  the  liver  and  kidneys,  and  tuber- 
cular deposits.  In  the  comparatively  small  number  of  cases  of  pelvi-rec- 
tal abscess  in  which  healing  occurs,  the  patient  still  has  to  meet  the  results 
of  extensive  cicatricial  contraction.  These  may  be  stricture  on  the  one 
hand,  or  incontinence  on  the  other;  with  the  subacute  inflammatory 
tendency  which  is  always  apt  to  attend  upon  a  cicatrix  at  the  anus  and 
cause  pain  and  uneasiness.  In  females  especially,  such  a  cicatrix  maybe 
the  cause  of  grave  trouble  with  the  genito-urinary  canal. 

Treatment. — It  may  be  considered  as  a  rule  to  which  there  are  few 
exceptions,  that  an  acute  inflammation  in  this  region  will  go  on  to  sup- 
puration; and  hence  that  antiphlogistic  measures  adopted  with  a  view 
to  securing  resolution  are  useless.  Early  incision  is,  therefore,  the  only 
rational  treatment,  and,  where  properly  performed,  this  may  result  in 
cure  without  the  formation  of  fistula.     Allingham '  goes  so  far  as  to  say 

'  Op.  cit  ,  p.  16. 


AB8CE68    AND   FISTULA.  77 

that  by  this  means  he  can  almost  guarantee  that  there  shall  be  no  fistula. 
The  incision  should  radiate  from  the  anus  to  avoid  as  far  as  possible  the 
section  of  nerves;  and  should  be  free  enough  to  secure  the  escape  of  pus, 
not  only  at  the  time,  but  while  the  abscess  is  healing.  If  there  be  bur- 
rowing in  any  direction,  the  incision  should  be  prolonged  to  correspond; 
and  the  finger  should  be  passed  as  far  as  possible  into  all  parts  of  the 
cavity  to  break  down  all  partitions.  The  wound  should  then  be  stufifed 
with  lint  wet  with  carbolized  oil,  and  a  drainage  tube  inserted.  The 
secret  of  success  will  be  found  to  lie  in  securing  a  free  outlet  for  pus, 
and  thus  preventing  burrowing. 

These  abscesses  should  not  be  laid  open  into  the  rectum — a  point 
which  is  genenilly  misunderstood  in  practice,  because  of  the  confounding 
of  an  abscess  which  which  may  ultimately  result  in  a  fistula  with  fistula 
itself.  The  treatment  is  that  of  abscess,  and  not  that  of  fistula,  and  is 
especially  directed  toward  the  prevention  of  fistula. 

Even  should  the  abscess  have  already  opened  into  the  bowel,  healing 
may  still  be  secured  by  following  this  line  of  treatment,  with  suitable 
means  for  keeping  the  rectum  empty,  and  a  laying  open  of  the  lower  end 
of  the  rectum  may  be  avoided.  After  a  fistula  is  fully  formed  and  all 
attempts  at  closure  have  failed,  the  usual  operation  of  dividing  the  track 
into  the  bowel  may  be  necessary,  but  it  should  always  be  undertaken  with 
the  expectation  of  disastrous  consequences  to  the  retentive  powers  of  the 
sphincters.  Incontinence  to  a  greater  or  less  extent  is  almost  sure  to 
follow  such  a  free  division  of  both  sphincters  and  of  the  bowel  above 
them. 

Incontinence  depends  more  upon  division  of  the  internal  than  of  the 
external  sphincter,  and  is  more  apt  to  follow  a  double  division  of  the 
fibres  than  a  single  one.  For  this  reason  the  surgeon  should  always  en- 
deavor to  leave  a  few  fibres  at  least  of  the  internal  muscle  in  any  opera- 
tion, and  the  incision  should  always  be  directly  and  not  obliquely  across 
the  fibres  of  the  muscle.  It  is  also  well  to  remember  that  incontinence 
is  always  more  apt  to  result  from  division  of  the  muscles  in  the  female 
than  in  the  male. 

Even  when  incontinence  has  resulted,  the  case  may  be  capable  of  re- 
lief in  this  regard  by  an  operation  with  the  cautery,  which  will  be 
described  in  speaking  of  prolapse.  I  have  seen  marked  benefit  in  this 
sad  condition  result  from  this  simple  operation  combined  with  the  per- 
sistent use  of  a  rectal  bougie  and  such  other  measures  as  are  calculated 
to  increase  the  power  of  the  sphincter,  and  I  am  much  less  inclined  to 
despair  of  giving  relief  in  these  cases  than  formerly.  In  one  case  sent 
me  by  Dr.  McC ready,  of  New  York,  in  which  a  considerable  degree  of 
incontinence  resulted  from  an  ischio-roctul  abscess,  this  mode  of  treat- 
ment patiently  followed  for  some  months  has  almost  entirely  relieved  the 
condition;  so  that  where  solid  fieces  at  first  escaped  him  there  is  now  a 


78  DISEA.SES    OF    THE    BECTCM    AXD    ANUS. 

good  degree  of  contractile  power,  and  the  patient  is  only  troubled  with 
an  occasional  discharge  of  the  rectal  mucus  in  small  quantity. 

Fistula. — A  fistula  which  is  not  due  to  a  perforation  of  the  rectal 
wall  from  within  is  the  result  of  a  previous  abscess,  and,  therefore,  in 
enumerating  the  causes  of  abscess  those  of  fistulae  have  also  been  given. 
Like  the  abscesses  from  which  they  arise,  they  may  well  be  divided  into 
superficial  and  deep;  or  into  those  of  the  anus,  which  are  subcutaneous, 
and  involve  at  the  most  only  a  few  fibres  of  the  external  sphincter,  and 
those  of  the  rectum  and  pelvis,  which  open  into  the  bowel  at  a  higher 
point.  Both  the  superficial  and  deep  may  also  be  divided  into  the  com- 
plete, or  those  which  open  both  on  the  skin  and  into  the  bowel;  the  ex- 
ternal, which  open  only  on  the  skin,  and  the  internal,  which  have  an. 
opening  only  within  the  bowel  (Fig.  27). 


Fis.  27. —Varieties  of  fistula  (Gosselin).    A,  anus;  R,  rectum;  B,  complete  fistula;  C,  blind  in- 
ternal fistula;  D,  blind  external  fistula. 

Superficial  Fistulm. — On  account  of  the  special  laxity  of  the  submu- 
cous connective  tissue  in  this  region,  already  noticed,  abscesses  show  little 
tendency  to  spontaneous  closure,  and  fistula  is  the  common  result  when 
left  to  their  own  course.  In  the  subcutaneous  fistula,  the  external  orifice 
may  be  at  some  distance  from  the  anus,  or  in  the  radiating  folds.  It 
may  be  so  small  as  to  escape  the  eye  in  a  cursory  examination,  unless  a 
drop  of  pus  chance  to  be  squeezed  out  of  it  by  the  pressure  of  the  fingers 
in  pulling  open  the  parts;  and  when  discovered,  it  may  not  admit  the  end 
of  an  ordinary  probe.  The  surgeon  should,  therefore,  always  be  provided 
with  a  probe  of  small  size  and  of  pure  silver,  which  admits  of  being  read- 
ily bent,  for  using  in  these  examinations. 

The  presence  of  more  than  one  external  orifice  is  rare  in  subcutaneous 
fistulae;  and  an  internal  opening  Avill  be  found  in  the  great  majority  of 
cases,  if  properly  searched  for.  The  only  way  to  settle  the  question  of 
the  presence  or  absence  of  an  internal  opening  in  any  doubtful  case  is  by 
opening  the  anus  with  a  speculum  and  injecting  milk  through  the  exter- 
nal orifice.  In  the  vast  majority  of  cases  the  milk  will  be  found  in  the 
rectum,  and  the  internal  orifice  will  be  found  just  within  the  external 
sphincter. 


AB8GE88    AND   FISTULA.  79 

It  may  sometimes  be  felt  in  this  location  by  the  educated  finger  as  a 
small  tubercle,  and  in  other  cases  it  is  marked  by  a  distinct  loss  of  sub- 
stance. In  some  the  internal  opening  will  be  found  in  the  radiating 
folds  entirely  below  the  fibres  of  the  sphincter,  and  in  others  it  may  be 
much  higher  up  the  bowel.  ■ 

The  internal  orifice  does  not  in  all  cases  mark  the  superior  limit  of  the 
fistulous  track.  This  may  run  several  inches  up  the  bowel  under  the 
mucous  membrane,  when  the  internal  orifice  is  just  within  the  external 
sphincter  (Figs.  28,  29). 


Fio.  28.  Fio.  29. 

Figs.  28,  29.— Fistulae  with  double  tracks  (MoUiere). 
Fig.  38.— AB,  deep  submuscular  track  resulting  from  an  iscliio- rectal  abscess.    AI,  submucous 
track  running  up  and  down  the  bowel. 

Fig.  29.— DE,  Subtegumentarf  and  submucous  fistula  with  Internal  and  external  opening. 
DF,  deep  submuscular  track,  having  same  iatemal,  but  separate  external  opening. 

The  track  of  a  fistula  is  sometimes  straight,  extending  directly  from 
one  orifice  to  the  other;  in  other  cases  a  track,  properly  speaking,  does 
not  exist  and  both  orifices  open  directly  into  the  original  abscess  cavity. 
If  the  external  orifice  be  very  small,  the  cavity  may  at  any  time  become 
distended  with  pus  and  give  rise  to  all  the  symptoms  of  a  fresh  abscess, 
till  the  pus  finds  an  exit  either  through  the  old  opening  or  a  new  one. 
The  external  orifice  of  a  true,  straight  fistulous  track  is  generally  large 
and  sometimes  free  enough  to  allow  of  the  escape  of  gas.  The  track  is 
lined  with  lardaceous  tissue  the  result  of  chronic  inflammation,  and  in  this 
may  be  found  numerous  blood-vessels  of  new  formation.  This  tissue,  by 
preventing  all  contact  of  the  walls,  necessarily  prevents  healing.  On  the 
other  hand,  the  track  is  sometimes  lined  with  healthy  granulations  which 

'  Kibes:  Recherches  sur  la  situation  de  rorifice  interne  de  la  flstule  de  Tanus. 
Rev.  MM.,  t.  i.,  1820. 


80  DISEASES   OF   THE    KECTUM    AND    ANUS. 

are  capable  of  being  formed  into  new  tissue,  and  for  this  reason  a  fistula 
will  sometimes  heal  spontaneously. 

The  history  will  sometimes  afford  valuable  information  as  to  the  gen- 
eral character  of  the  case.  The  history  of  a  slight  abscess  and  the  escape 
of  a  small  amount  of  pus  generally  means  an  insignificant  fistula  witli 
external  and  internal  openings  near  the  margin  of  the  anus;  while,  on  the 
other  hand,  the  history  of  a  prolonged  inflammation  and  a  free  discharge 
of  pus  means  a  large  abscess  cavity  mounting  to  a  considerable  height, 
and  with  its  internal  orifice  at  a  correspondingly  high  point. 

The  symptoms  caused  by  this  class  of  fistulas  vary  greatly.  At  first 
they  are  those  of  the  abscess  in  which  they  originate.  After  that  the 
one  great  symptom  is  the  incessant  discharge,  sometimes  slight,  at  others 
abundant;  sometimes  purulent,  at  others  serous;  always  fcetid;  sometimes 
containing  faeces  and  gas.  It  is  generally  the  stoppage  of  the  dis- 
charge and  the  consequent  filling  of  the  track  or  abscess  cavity  which 
induces  the  patient  to  seek  the  surgeon.  Besides  the  discharge  there 
may  be  no  symptoms  at  all,  or  there  may  be  more  or  less  uneasiness  in 
the  part,  and  pain  on  defecation,  with  the  constipation  which  arises  from 
the  fear  of  a  passage,  and  the  symptoms  to  which  it  gives  rise.  Such  a 
state  of  affairs  may  exist  for  many  years  without  aggravation,  or  without 
causing  the  patient  to  seek  relief. 

Deep  FistulcB. — Deep  or  submuscular  fistulae  differ  greatly  in  their 
extent  and  gravity  from  those  last  described.  In  them  the  track  is  large 
and  often  double  or  branching,  and  the  external  opening  may  be  far 
away  from  the  anus.  The  whole  perineum  and  gluteal  region  will  some- 
times be  found  to  be  perforated  by  openings.  In  a  case  sent  to  me  by 
Dr.  E.  W.  Taylor,  of  New  York,  I  easily  counted  between  twenty  and 
thirty  of  these  discharging  points,  and  the  whole  perineum  and  sur- 
rounding region  were  hard,  brawny,  and  infiltrated.  The  man,  under 
the  pressure  of  his  sufferings  probably,  had  become  a  confirmed  opium 
eater  and  was  in  a  deplorable  plight. 

The  track  in  some  of  these  cases  has  been  known  to  take  a  remarka- 
bly irregular  course.  Sir  A.  Cooper'  mentions  an  autopsy  where  a  fistula 
opened  in  the  groin,  followed  the  course  of  the  spermatic  cord,  and  ended 
in  what  seemed  like  an  ordinary  fistula  in  ano;  and  cases  in  which  the 
pus  has  burrowed  under  the  gluteal  muscles  and  finally  opened  in  tlie 
thigh  or  even  nearly  at  the  popliteal  space,  are  not  uncommon. 

Blind  Internal  Fistula. — Fistulae  with  internal  openings  alone  have  u 
somewhat  special  pathology.  When  caused  by  an  abscess  it  is  generally 
by  one  of  the  deep  variety  which  has  opened  into  the  rectum  high  up  and 
continues  to  discharge  in  this  way.  The  abscess  causing  such  a  fistula 
may,  however,  be  a  small  submucous  one,  and  the  symptoms  will  then 
be  pain,  spontaneous  discharge  of  pus  from  the  bowel,  and  subsequently 

'  Lee.  on  Prin.  and  Prac.  of  Surg.,  with  notes  by  Tyrell,  t.  ii.,  p.  326. 


▲B80B88    AND    FISTULA.  81 

pain  after  defecation  resembling  that  of  a  fissure.  There  is  another,  and 
l)erhaps  more  common  class  of  internal  fistuljB  in  which  the  opening  is 
not  tlie  result  of  the  breaking  of  an  abscess,  but  in  which  the  opening  is 
first  formed  by  ulceration  and  the  track  is  a  secondary  consequence. 
This  pathological  fact  was  proved  by  the  well-known  investigations  of 
Ribes,  who  believed  that  the  internal  orifice  was  always  the  first  formed, 
but  here  he  was  undoubtedly  in  error. 

A  circumscribed  ulcer  which  shall  perforate  the  mucous  membrane 
and  result  in  internal  fistula  may  be  due  to  several  causes:  to  the  inflam- 
mation of  one  of  the  lacunas  just  above  the  sphincter  from  the  lodgment 
within  it  of  a  particle  of  hard  faeces;  to  rupture  of  an  inflamed  internal 
haemorrhoid;  to  the  application  of  strong  acids  to  haemorrhoids;  to  oper- 
ations upon  the  rectum  generally  for  haemorrhoids;  and  to  the  peculiar 
ulceration  met  with  in  tubercular  patients,  but  not  necessarily  tubercular 
in  its  nature. 

Such  a  condition  is  a  very  painful  one.  The  opening  which  may  be 
large  enough  to  show  a  distinct  loss  of  substance  to  the  touch,  catches 
and  retains  particles  of  faeces,  causing  a  burning  pain  which  may  last 
many  hours  after  defecation.  As  a  result  of  the  opening  an  abscess  forms 
after  a  time  with  the  usual  symptoms,  the  induration  of  which  may  be 
felt  externally.  When  the  abscess  is  small  and  the  induration  not  ex- 
tensive a  speculum  examination  may  reveal  the  ulcer;  but  the  fistulous 
track  and  abscess  may  escape — a  mistake  which  will  render  all  treatment 
directed  toward  the  cure  of  the  ulcer  of  no  avail.  There  may  indeed  be 
several  ulcers,  only  one  of  which  has  a  fistula  connected  with  it. 

Treatment. — A  fistula  may  heal  spontaneously  or  after  a  very  slight 
excitement  to  reparative  action,  such  as  the  mere  passage  of  a  probe  in 
making  an  examination.  It  has  been  mentioned  that  the  track  is  some- 
times lined  with  healthy  granulations,  and  that  these  may  result  in 
new  tissue  which  shall  close  it;  but  this  can  never  occur  after  the  usual 
infiltrated  tissue  has  once  been  formed,  which  is  seen  in  all  old  cases. 
Allingham'  relates  several  cases  of  spontaneous  cure,  and  estimates  the 
proportion  in  which  it  may  occur  as  about  one  per  cent. 

Setting  aside  these  cases,  we  are  at  once  brought  to  the  question 
which  will  often  be  asked  by  the  patient,  and  which  the  surgeon  may 
not  always  be  able  to  answer  to  his  own  satisfaction,  whether  or  not  it 
is  always  best,  or  even  safe  to  try  and  cure  a  fistula.  In  certain  cases 
of  Bright's  disease,  cancer,  cardiac  and  hepatic  affections,  etc.,  all  sur- 
gical interference  may  be  plainly  contra-indicated;  but  the  question  is 
most  apt  to  arise  in  connection  with  pulmonary  affections.  There  can 
be  little  doubt  that  phthisical  patients  are  especially  predisposed  to  this 
affection,  and  the  reason  is  probably  in  great  measure  a  mechanical  one, 
dejiending  upon  a  loss  of  fat  in  the  ischio-rectal  fossa  and  a  resulting 

•  Op.  cit.,  p.  24. 
6- 


Oa  DISEASES    OF    THE    RECTUM    AND    AKU8. 

loss  of  support  to  the  haemorrhoidal  veins.  From  this  there  results  a 
venous  congestion  and  final  dilatation  or  rupture  of  the  vessels,  which, 
with  the  cough  and  concussion,  leads  eventually  to  abscess. 

I  believe  it  to  be  a  safe  rule  to  operate  upon  phthisical  patients  as 
upon  others,  being  led  by  the  idea  that  one  exhausting  disease — phthisis 
— is  better  than  two — phthisis  and  fistula.  I  have  many  times  followed 
this  rule  with  happy  results  as  to  improved  general  health  after  the  cure 
of  the  fistula.  Once  only  has  it  happened  to  me  to  see  the  cure  of  a 
fistula  followed  by  a  marked  increase  of  the  lung  trouble,  and  even  in 
such  a  case  the  relation  between  cause  and  effect  cannot  be  established. 
I  have  also  yet  to  meet  the  first  case  which,  under  suitable  and  careful 
general  and  local  treatment,  refused  to  heal  after  the  operation.  There 
are  several  rules  which  should  be  carefully  regarded  in  this  class  of  cases, 
however.  No  cautious  practitioner  would  think  of  operating  either  in 
a  very  advanced  or  a  rapidly  advancing  lung  trouble.  Cough,  when  vio- 
lent and  frequent,  is  also  a  decided  conti-a-indication,  interfering,  as  it 
does  very  certainly,  with  the  healing  of  the  wound.  The  following  case 
will  perhaps  illustrate  the  line  of  treatment  to  be  followed  in  a  general 
way. 

Case  V. — A  theological  student,  aged  twenty-eight,  applied  to  me 
from  a  neighboring  city  for  relief  from  a  large  subcutaneous  abscess  with 
an  internal  opening  within  the  sphincter,  and  an  external  one  at  some  dis- 
tance from  the  anus.  The  probe  could  easily  be  passed  a  considerable 
distance  in  every  direction  beneath  the  undermined  skin.  The  discharge 
was  very  profuse.  This  condition  had  existed  for  several  months;  the 
patient  was  much  reduced  in  weight,  there  was  consolidation  in  the  apex 
of  one  lung,  with  a  history  of  phthisis  and  hasmorrhages. 

The  internal  and  external  orifices  were  connected  by  an  incision  in- 
volving the  external  sphincter,  and  the  abscess  cavity  was  laid  open  for 
a  distance  of  four  inches  along  the  perineum,  and  dressed  with  picked 
lint.  After  a  fortnight's  rest  in  his  room,  the  patient  being  partially 
dressed  most  of  the  time,  and  spending  his  days  on  the  lounge  or  easy 
chair  rather  than  in  bed,  reparative  action  seemed  to  come  to  a  stand- 
still, and  with  careful  directions  as  to  dressing  the  wound,  I  sent  him  off 
into  the  mountains.  He  reported  at  my  office  after  an  interval  of  three 
months  spent  in  the  woods,  during  which  time  he  had  freouently  been  on 
horse-back  several  hours  at  a  time.  The  change  in  his  general  condition 
was  very  remarkable,  he  having  gained  nearly  twenty  pounds  in  weight. 
The  abscess  cavity  was  nearly,  but  not  quite  closed,  and  again  he  re- 
turned to  the  country,  with  the  understanding  that  he  should  report  in 
the  city  every  fortnight.  In  just  six  months  from  the  operation  the 
wound  was  entirely  healed,  there  had  been  no  exacerbation  in  the  lung 
troubles,  and  the  patient  was  in  better  general  condition  than  for  years 
previous. 

In  cases  of  fistula  in  phthisical  patients,  the  sphincters  should  be 


AB8CES8    AND   FIBTULA.  83 

interfered  with  as  little  as  possible,  as  they  are  apt  to  be  weak  at  the 
best  The  internal  orifice  is  apt  to  be  large  and  ragged,  and  the  exter- 
nal may  be  the  same.  The  tendency  to  undermine  the  skin  is  always 
marked,  and  the  discharge  is  generally  thin  and  watery. 

Cauterization.— ^It  is  not  necessary  even  to  enumerate  the  various  sub- 
stances which  from  time  out  of  date  have  been  advocated  for  this  purpose. 
Among  those  for  which  good  results  have  been  claimed,  iodine  holds  the 
first  rank.'  There  is  no  doubt  that  that  by  its  nse  certain  fistulas  and 
abscesses  may  be  made  to  heal,  but  the  plan  is  uncertain  and  not  very 
reliable. 

The  operation  consists  in  closing  the  internal  opening  with  a  finger 
in  the  rectum  and  then  injecting  the  fluid  with  a  small  syringe  through 
the  external  orifice,  using  pressure  enough  on  the  track  to  bring  the 
fluid  into  contact  with  every  part.  In  the  place  of  iodine,  nitrate  of 
silver  either  in  solution  or  fused  upon  a  probe;  the  tincture  of  iron;  or 
carbolic  acid,  may  be  used.  The  galvano-cautery  wire,  or  a  simple  hot 
iron  may  also  be  employed  to  modify  the  track;  and  a  fine  sea-tangle 
tent  carefully  introduced  will  sometimes  set  up  reparative  action.  By  any 
of  these  means  failure  will  be  the  rule,  but  success  may  occasionally  be 
secured  after  faithful  trial. 

Tlie  ligature. — Under  the  head  of  the  ligature  may  be  included  also  its 
different  modifications — ecrasement  lineaire,  elastic  ligature,  and  the 
galvano-cautery  wire. 

The  method  of  cure  by  the  simple  ligature  consists  in  passing  a  strong 
cord  through  the  fistula  from  the  external  opening,  through  the  internal, 
and  out  at  the  anus,  then  in  tying  the  two  ends,  and  tightening  the  loop 
from  day  to  day  till  the  tissue  included  is  divided.  The  operation  is 
generally  effectual,  but  it  is  also  painful,  tedious,  and  uncertain.  It  is  a 
substitute  for  the  knife,  a  concession  to  the  fear  of  being  cut,  and  it  is 
free  from  haemorrhage;  but  it  only  accomplishes  in  the  end,  and  some- 
times after  weeks  of  suffering,  what  the  knife  accomplishes  in  a  moment; 
and  except  for  the  single  fact  that  by  its  use  haemorrhage  may  be  avoided 
it  would  bear  no  comparison  with  the  latter. 

If  this  mode  of  treatment  is  for  any  reason  decided  upon,  there  are 
certJiin  modifications  of  the  operation  which  are  much  to  be  preferred  to 
the  simple  cord.  The  method  of  immediately  cutting  through  the  tis- 
sues by  attaching  the  ends  of  the  cord  to  the  handle  of  an  6craseur  {ecrase- 
ment lineaire)  is  a  much  better  way  of  attaining  the  same  end  which  is 
clue  to  Chassaignac.  There  are,  however,  two  methods  of  dividing  the 
tissues  which  are  still  better  than  this — one  by  the  galvano-cautery  wire, 
the  other  by  the  elastic  ligature.  The  galvano-cautery  wire  has  the  same 
advantage  over  the  knife  as  the  ligature  in  preventing  haemorrhage;  and 
itiis  not  particularly  painful  in  its  application.     In  using  it,  as  litteheat 

'  Boinet:   "Traite  d'iodotherapie." 


84 


DISEASES    OF   THB   EECTDM    AND    ANUS. 


should  be  used  as  is  possible  to  slowly  divide  the  tissue,  or  haemorrhage 
may  occur  and  all  its  advantages  be  lost.  On  account  of  the  expense  of 
the  apparatus,  and  the  skill  required  for  its  management,  this  method  has 
never  become  very  popular  with  the  general  practitioner,  but  it  is  very 
successful  in  the  hands  of  a  few. 

Probably  the  best  of  all  methods  next  to  the  knife  is  that  of  the  elastic 
ligature.  The  cord  in  this  case  is  of  solid  rubber  which  is  drawn  as  tightly 
as  possible — the  tighter  the  better — and  then  held  on  the  stretch  by 
slipping  a  soft  metal  ring  over  the  ends  and  squeezing  its  two  sides  to- 
gether close  up  against  the  tissues.  In  the  course  of  a  few  days  the  liga- 
ture will  be  found  to  have  cut  its  way  through  the  included  tissues,  the 
time  depending  on  the  quantity  and  quality  of  the  mass  to  be  cut. 

Various  devices  have  been  recommended  for  facilitating  the  passage  of 
the  ligature.     The  best  known  is  AUingham's,  Fig.  30.     In  using  it,  re- 


FiG,  30. 


remember  that  it  is  intended  to  draw  the  cord  from  the  rectum  out  of  the 
external  orifice,  and  not  vice  versa.  Helmuth,  of  New  York  has  modified 
the  instrument  and  I  think  with  advantage.  Fig.  31,  but  the  least  elaborate 


Fig.  31. 

and  most  effective  instrument  for  the  purpose  in  my  own  hands  is  a  simple 
silver,  eyed  probe  which  is  threaded  with  the  elastic  cord  and  then 
passed  from  the  external  orifice  through  the  track  and  out  at  the  anus.  I 
once  had  an  awkard  accident  with  AUingham's  instrument  which  broke 
in  my  hand  in  a  moderately  deep  and  hard  track. 

After  the  ligature  is  in  place,  the  patient  is  allowed  to  go  about  his 
ordinary  pursuits,  and  this  is  claimed  as  one  great  advantage  of  this 
method.  I  have  never  been  able  to  understand  why  cutting  with  a  string 
should  permit  of  any  more  liberty  than  cutting  with  a  knife.  The  patient, 
it  is  true,  will  generally  get  well  if  he  goes  about  while  the  string  is  doing 
its  work,  and  so  he  will  after  the  operation  with  the  knife;  but  in  both 
cases  the  healing  will  be  facilitated  by  rest.     The  operation  is  said  to  be 


AB8GE68    AND    FISTULA.  85 

painless.  I  have  not  found  it  so.  Both  the  passing  of  the  cord,  and  its 
tension  for  the  first  forty-eight  hours  have  been  bitterly  complained  of  in 
some  of  my  own  cases.  The  healing  has  already  begun  before  the  liga- 
ture comes  away;  but  with  the  dropping  out  of  the  cord  there  will  some- 
times be  found  a  considerable  slough  in  tlie  line  of  strangulation  which 
may  require  some  days  for  its  separation. 

The  elastic  ligature  has  undoubted^  advantages  over  the  knife  in  cases 
where  the  latter  is  contra-indicated  by  the  fear  of  haemorrhage;  as  in  a  fis- 
tula running  high  up  the  bowel  where  haemorrhage  may  be  a  serious  mat- 
ter; or  where  the  patient  refuses  to  submit  to  a  cutting  operation.  Of  all 
the  methods  of  cutting  with  a  string  it  is  the  best,  but  after  all,  it  is  only 
a  substitute  for  the  knife,  and  for  my  own  part  [  must  plead  guilty  to  a 
preference  for  cutting  with  a  knife  when  cutting  is  necessary. 

Incision. — The  operation  for  fistula  by  incision  may  be  greatly  facili- 
tated by  the  observance  of  several  minor  details.  In  this  as  in  other 
operations  on  the  part,  the  bowels  should  be  thoroughly  emptied  on  the 
previous  day.  Care  must  be  exercised,  lest  in  the  endeavor  to  free  the 
alimentary  canal  a  diarrhoea  be  excited,  for  this  will  prove  anything  but 
an  agreeable  complication  for  the  operator.  In  all  cases  in  which  the 
track  is  of  any  considerable  depth,  or  in  which  on  acconnt  of  the  sensi- 
tiveness of  the  patient  the  surgeon  has  not  been  able  to  assure  himself  of 
the  exact  extent  of  the  disease  and  the  absence  of  any  side  tracks  or 
diverticula,  ether  should  be  given  and  the  anus  gently  and  completely 
dilated  before  the  operation.  It  is  only  in  the  simplest  cases  that  the 
incision  may  be  made  without  ether,  and  then  the  best  chance  of  a 
thoroughly  satisfactory  exploration  is  missed,  and  the  way  is  opened  for 
an  incomplete  and  therefore  unsuccessful  operation. 

With  regard  to  position  the  operator  may  choose  between  placing  the 
patient  on  the  affected  side  or  on  the  back.  In  women  the  former  is 
generally  preferable.  A  director  with  probe  point  should  be  passed 
through  the  external  orifice  into  the  bowel  and  brought  out  at  the  anus 
by  the  index  finger  of  the  other  hand,  which  should  in  any  case  be  passed 
into  the  bowel  before  the  probe  is  inserted  into  the  external  opening. 
The  track  should  now  be  carefully  and  thoroughly  explored  and  its 
extent  discovered.  This  should  be  done  deliberately  and  without  haste, 
and  hence  the  advantage  of  an  ansBsthetic.  When  the  patient  is  not 
etherized  there  is  always  a  temptation  when  the  end  of  the  probe  is  felt 
against  the  finger  in  the  rectum,  to  bring  it  out  at  the  anus,  follow  it 
instantly  with  the  bistoury,  and  quiet  the  sufferer  with  the  cheering  assur- 
ance that  all  is  finished;  but  a  seemingly  insignificant  case  may  have  a 
deep  track  connected  with  it  which  must  be  divided  before  a  cure  can  be 
effected. 

Having  by  careful  examination  decided  just  how  much  cutting  is  to 
done,  the  choice  of  the  instrument  rests  with  each  operator.  In  simple 
cases  where  the  track  is  superficial,  I  frequently  use  a  knife  of  my  own 


86  DISEASES   OF   THE   EECTUM    AND    ANUS. 

invention  which  (like  most  new  inventions)  I  found  after  having  it  man- 
ufactured, exactly  resembled  those  in  use  in  the  fourteenth  and  fifteenth 
century,  though  somewhat  smaller  and  less  formidable  in  appearance.' 
It  is  represented  in  Fig.  32,  and  consists  of  a  flexible  probe  at  the  end  of 


Fig.  32.— Author's  Fistula  Knife. 

a  curved  bistoury.  The  probe  point  should  blend  as  gradually  as  possi- 
bly with  the  cutting  edge,  as  anything  like  a  shoulder  at  the  junction  of 
the  two  interferes  greatly  with  its  use.  I  have  thought  that  in  suitable 
cases  the  operation  was  rendered  more  speedy  and  less  painful  by  the  use 
of  this  combined  instrument;  but  it  is  not  well  adapted  to  those  cases  in 
which  the  track  runs  any  distance  up  the  bowel;  and  where  the  patient 
is  etherized  it  has  no  advantages  over  the  director  on  which  the  bistoury 
is  generally  passed.  It  is  especially  adapted  for  operating  without  ether. 
In  subcutaneous  fistulas  the  track  should  be  divided  from  the  external 
to  the  internal  orifice.  If  there  be  at  the  same  time  any  undermining  of 
the  skin  with  tracks  leading  off  in  different  directions,  these  also  should 
be  laid  open,  so  that  all  may  be  converted  into  an  open  wound.  For 
deep  fistulae  the  knife  or  scissors  should  be  strongly  made,  for  it  is  not  a 
very  difficult  matter  to  break  an  ordinary  scalpel  in  a  deep  fistula.     A 


Fig.  33. 

heavy  steel  director  may  also  be  snapped  in  an  attempt  to  bring  the  end 
out  of  the  anus  preparatory  to  making  the  incision;  and  should  the  in- 
ternal orifice  be  high  up,  and  the  external  at  some  distance  from  the 
anus,  so  that  the  amount  of  tissue  to  be  divided  is  large,  it  is  often  better 
to  use  the  wooden  gorget  to  guard  the  opposite  side  of  the  rectum  and 
*  dispense  with  the  director  after  the  knife  has  been  passed.  (Fig.  33.) 
The  end  of  the  knife  may  be  firmly  fixed  into  the  wood  and  both  with- 

'  I  am  indebted  to  my  friend,  Dr.  James  L.  Little,  for  calling  my  attention  to 
the  plates  in  Heister's  Surgery,  showing  these  instruments. 


AB80E88   AND   FISTULA.  87 

drawn  simultaneously,  or  the  incision  may  be  made  by  cutting  on  the 
gorget.  Allingham  prefers  a  pair  of  spring  scissors,  one  blade  of  which 
runs  in  a  director  the  groove  of  which  is  more  than  a  semicircle,  for  cut- 
ting deep  tracks.    (Fig.  34.) 


Fio.  SI.— Allineham's  Spring-Scissors  for  Fistula. 

Some  difference  of  opinion  exists  among  different  writers  as  to  the 
proper  method  of  treating  the  track  that  will  often  be  found  running 
along  the  bowel  above  the  internal  orifice,  and  directly  contrary  opinions 
are  taught  as  to  the  necessity  for  its  complete  division.  The  operation  is 
of  course  rendered  more  severe  by  the  division  of  such  a  sinus  in  addition 
to  the  fistula,  and  the  danger  of  haemorrhage  is  increased;  but  one  can 
never  be  sure  that  the  operation  will  be  successful  when  such  a  track  is 
left,  though  no  doubt  many  cases  have  turned  out  well.  With  regard  to 
haemorrhage  in  such  cases,  it  will  be  found  that  the  sinus  has  generally 
burrowed  under  the  mucous  membrane,  and  that  the  vessels  have  re- 
mained in  the  deeper  layers  of  the  bowel,  so  that  the  division  of  the  sinus 
does  not  of  necessity  involve  that  of  any  large  vessel,  though  it  extend  far 
up  the  bowel. 

Many  of  these  sinuses  may  best  be  divided  with  the  scissors,  and  the 
haemorrhage,  if  it  be  profuse,  dealt  witli  according  to  the  rules  already 
given.  If,  however,  haemorrhage  be  feared  beforehand,  the  track  may 
be  divided  with  the  ecraseur,  or  a  small  canula  may  first  be  passed, 
through  this  a  wire,  and  finally  by  means  of  the  wire  an  elastic  liga- 
ture. 

When  no  internal  orifice  can  be  found,  but  the  mucous  membrane 
feels  undermined,  and  the  probe  can  be  felt  by  the  finger  in  the  rec- 
tum, separated  only  by  a  thin  layer  of  mucous  membrane,  it  is  a  good 
plan  to  force  an  internal  opening  and  treat  the  fistula  as  though  it 
were  complete.  When  there  are  two  internal  openings,  both  should  be 
included  in  one  incision.  When,  after  the  incision,  the  diseased  integ- 
ument is  found  to  overlap  the  cut,  and  hang  into  it,  it  should  be  cut 
away,  and  in  old  tracks  the  healing  may  be  hastened  many  days  by  thor- 
oughly scraping  out  the  liirdaceous  wall  with  the  handle  of  the  scalpel, 
or  even  scarifying  it  in  several  places,  so  that  a  healthy  reparative  action 
may  be  set  up. 


88  DISEASES    OF    THE    BECTUM    AND    ANUS. 

In  cases  of  horse-shoe  fistula  with  two  external  orifices  and  one  in- 
ternal one,  it  is  generally  best  to  do  the  usual  operation  on  one  side  only, 
and  to  dilate  the  opening  on  the  opposite  side,  so  as  to  allow  of  free  es- 
cape of  pus. 

Where  the  fistulous  tracks  exist  in  great  numbers — twenty  or  thirty  in 
some  cases — two  or  three  operations  may  be  advisable  at  intervals, 
rather  than  to  attempt  to  do  all  at  one  sitting,  lest  the  patient's  reparative 
powers  should  be  unequal  to  the  task  thrown  upon  them.  In  such 
cases,  there  will  often  be  found  two  or  three  tracks  which  may  be  consid- 
ered as  primary,  into  which  the  others  run;  and  each  of  these,  with  its 
branches,  may  be  dealt  with  at  a  separate  operation.  Many  of  the  tracks 
will  be  found  to  run  away  from  the  bowel  under  the  skin  of  the  buttock 
or  toward  the  scrotum,  and  these  may  be  induced  to  heal  by  laying 
them  open,  without  interfering  with  the  sphincters.  It  will  sometimes 
be  necessary  to  divide  the  sphincter  several  times,  however,  before  the 
cure  can  be  completed,  and  a  certain  degree  of  incontinence  may  be 
expected  as  a  result. 

In  such  cases,  the  anal  region  is  generally  greatly  hardened  and  in- 
filtrated, and  free  haemorrhage  may  be  expected.  The  best  weapon  with 
which  to  meet  it  is  the  cautery  of  Paquelin. 

In  the  matter  of  dressings  after  the  incision,  much  skill  may  be  dis- 
played. Immediately  after  the  operation,  a  dressing  of  dry  picked  lint, 
or  if  there  be  an  abscess  cavity,  of  lint  soaked  in  carbolized  oil,  is  as  good 
as  any,  and  this  should  be  kept  in  place  by  a  T-bandage.  To  save  the 
patient  as  much  pain  and  annoyance  as  possible,  this  should  not  be  re- 
moved till  suppuration  has  been  established.  Subsequent  dressings 
may  be  of  the  same  material,  and  should  be  changed  daily.  The  wound 
should  not  be  tightly  packed  with  lint.  It  will  heal  from  the  bottom 
if  its  surfaces  are  kept  apart  or  separated  daily  by  the  finger  of  the  sur- 
geon. Care  is  always  necessary  to  prevent  an  immediate  union  of  the 
cutaneous  edges  of  the  incision,  and  I  have  seen  a  remarkably  well- 
pleased  patient  come  to  me  and  report  himself  as  entirely  cured  a  week 
after  I  had  divided  his  fistula,  in  consultation  with  his  medical  attend- 
ant, and  have  found  on  examination  that  the  incision  had  healed  very 
kindly  by  first  intention  through  its  whole  extent,  and  that  the  fistulous 
track  was  exactly  as  it  was  before  the  cut. 

Healing  may  be  indefinitely  delayed  by  too  frequent  dressings  or 
by  stuffing  the  wound  tightly  with  lint,  with  the  intention  of  forcing  it 
to  heal  from  the  bottom.  Under  such  treatment,  healthy  granulations 
may  entirely  disappear,  and  the  cut  surface  assume  a  mucous-membrane- 
like  appearance,  and  so  remain.  Standing  or  walking  always  delays,  and 
may  sometimes  entirely  prevent  healing. 

During  the  treatment,  the  burrowing  of  pus  and  the  formation  of  a 
new  pocket  should  always  be  carefully  watched  for,  and  met  by  incision. 

The  haemorrhage  in  an  ordinary  operation  for  fistula  is  seldom  pro- 


ABSCESS    AND   FISTDI.A.  89 

fuse  enough  to  cause  the  surgeon  any  uneasiness,  and  is  almost  alvrays 
easily  controlled  by  packing  the  incision  with  lint,  and  making  firm  pres- 
sure with  a  compress  held  in  place  by  a  T-bandage.  A  free  arterial 
haemorrhage  from  a  vessel  well  up  the  rectum  may,  however,  be  alarm- 
ing, and  if  not  controlled  by  the  admission  of  air  or  the  application  of 
ice  to  the  part,  the  rectum  must  be  tamponed. 

Fistulaj  of  the  blind  internal  variety  can  only  be  dealt  with  rationally 
by  incision.  A  speculum  should  first  be  introduced  and  a  silver  director 
bent  into  the  form  of  a  hook  passed  into  the  orifice  and  brought  down  to 
the  bottom  of  the  track;  with  this  as  a  guide  the  fistula  may  be  opened 
into  the  bowel. 

The  incision  should  always  be  continued  through  the  sphincter  and 
the  anus,  so  that  the  wound  may  be  properly  dressed  and  drained;  other- 
wise the  operation  will  merely  serve  to  convert  a  small  internal  opening 
into  a  larger  one.  An  operation  of  this  kind  is  always  more  apt  to  be 
followed  by  a  concealed  haemorrhage  into  the  rectum  than  one  for  a  com- 
plete fistula,  and  this  should  be  guarded  against  by  a  careful  plugging  of 
the  wound  and  by  the  application  of  dry  persulphate  of  iron  if  necessary. 

The  abscess  in  connection  with  a  blind  internal  fistula  may  sometimes 
be  detected  by  the  induration  which  may  be  felt  through  the  skin  of  the 
ischio-rectal  fossa.  In  such  a  case,  after  the  director  has  been  passed  into 
the  internal  orifice,  a  counter-opening  should  be  made  into  the  abscess 
through  the  skin,  using  the  director  for  a  guide  for  the  incision.  In  this 
way  the  blind  internal  variety  is  changed  into  the  complete,  and  the  usual 
operation  of  division  into  the  bowel  may  be  performed. 

After  what  has  been  said  of  the  origin  and  extent  of  abscesses  of  the 
superior  pelvi-rectal  space,  it  is  evident  that  there  may  result  from  them 
a  class  of  fistulje  wliich  are  not  to  be  operated  upon  by  any  of  the  methods 
we  have  described — fistulae  so  deep  and  extensive  as  to  contra-indicate  all 
operative  interference.  And  yet  much  may  be  done  even  in  the  worst 
cases  of  this  kind,  and  by  proper  treatment  some  may  be  cured.  The 
first  attempt  of  the  surgeon  should  always  be  toward  effecting  a  cure 
without  cutting  the  track  into  the  bowel.  External  and  comparatively 
free  incisions  may  be  made,  which  shall  not  implicate  the  anus,  and 
through  them  drainage  tubes  may  be  passed  into  the  abscess  cavity  so  that 
it  niiiy  be  freely  emptied.  Through  the  drainage  tube  stimulating  in- 
jections may  be  made,  and  the  abscess  treated  as  an  abscess  elsewhere 
would  be,  by  rest  and  attention  to  the  general  health.  A  cure  may  some- 
times be  effected  in  this  way  in  a  very  unpromising  case. 

Where  the  track  has  burrowed  to  great  length,  much  may  be  accom- 
plished by  modified  operations.  In  a  track,  for  example,  which  has  one 
opening  nejir  the  anus  and  another  in  the  middle  of  the  thigh,  a  counter 
opening  may  be  made  between  the  two  and  the  further  extremity  induced 
to  heal  while  drainage  is  maintained  from  the  middle  ojjeniug  by  the  use 
of  injections  or  caustic  applications.     Should  these  means  not  succeed 


90  DISEASES   OF   THE   KEOTUM    AND    ANUS. 

and  should  it  appear  that  a  free  division  was  likely  to  result  in  a  cure, 
the  ineision  may  be  made;  according  to  the  ordinary  rules  of  surgery. 
Such  operations  have  been  done,  and  tracks  of  great  length  extending 
under  the  gluteal  muscles  have  been  divided  with  the  ecraseur  with  good 
results.  I  have  myself  followed  a  track  directly  across  the  perineum  and 
exposed  the  membranous  urethra  in  the  incision,  dividing  in  the  opera- 
tion the  sphincters  four  different  times.  Such  operations  may  sometimes 
be  necessary  to  save  life,  but  they  maybe  too  great  for  the  patient's  powers 
of  recuperation. 

In  fistula  complicating  stricture  of  the  rectum,  attention  should  always 
first  be  turned  to  the  latter,  for  if  this  can  be  cured  there  is  a  prospect 
that  the  former  may  undergo  spontaneous  closure,  and  if  the  stricture  be 
not  relieved  it  will  be  of  little  avail  to  cut  the  fistula.  Many  awkward 
mistakes  have  happened  to  good  surgeons  by  failing  to  detect  this  com- 
plication of  diseases. 


HiEMOBKHOIDS.  91 


CHAPTER  TL 

HEMORRHOIDS, 

Definition. — Diriaion  into  External  and  Internal. — Differences  between  the  two 
Varieties. — External  Hemorrhoids. — Pathology. — Inflamed  Haemorrhoids. 
— Treatment. — Means  of  Prevention.— Palliative  Treatment. — Excision. — In- 
ternal Haemorrhoids. — Division  into  Capillary,  Arterial,  and  Venous. — 
Description  of  Capillary  Variety,  of  Venous  Variety,  of  Arterial  Variety. — 
Symptoms  of  Internal  Haemorrhoids. — Strangulation. — Diagnosis. — Treat- 
ment of  Internal  Haemorhoids. — Palliative  Treatment. — Constitutional  and 
Local  Means  of  Palliation. — Treatment  of  Strangulation. — Curative  Treat- 
ment.— Haemorrhoids  Associated  with  Uterine  Disease. — Symptomatic  Haem- 
orrhoids.— Radical  Cure. — Caustics. — Dangers  of  Nitric  Acid. — Vienna  Paste. 
— Treatment  by  Carbolic  Acid  Injections;  Cases  and  Cures. — Advantages  of 
this  Treatment. — Treatment  by  Ligature.— Description  of  Operation. — 
Operation  with  Clamp  and  Cautery. 

Hemorrhoids  may  be  defined  as  varicosities  of  the  anal  or  rectal 
vessels.  They  may  present  themselves  under  various  forms  and  condi- 
tions owing  to  changes  in  their  substance;  but  the  first  step  in  their 
formation  is  always  an  enlargement  and  dilatation  of  the  veins  or  arteries 
or  both. 

Haemorrhoids,  for  convenience,  may  be  divided  into  external  and 
internal;  and  these  may  always  be  distinguished  from  each  other,  though 
both  may  exist  at  the  same  time  in  the  same  patient.  An  external 
haemorrhoid  originates  in  the  subcutaneous  veins  which  surround  the 
anus;  it  is  therefore  entirely  below  the  sphincter  muscle,  and  though  it 
may  be  partially  covered  by  mucous  membrane,  it  does  not  come  from 
the  rectum  proper,  nor  can  it  be  forced  above  the  external  sphincter 
muscle.  An  internal  hiBmorrhoid  originates,  on  the  other  hand,  within 
the  rectum,  and  may  exist  for  a  long  time  without  appearing  externally. 
When  it  does  show  itself  outside  of  the  anus,  it  is  a  result  of  straining, 
of  increase  in  size,  or  of  a  lax  condition  of  the  sphincter,  and  after  long 
exposure  outside  the  body  it  may  become  changed  in  character  and  appear- 
ance, till  the  mucous  membrane  covering  it  takes  on  something  of  the 
character  of  integument;  but  it  may  still,  with  proi)er  management,  be 
returned  within  the  bowel,  though  it  may  not  remain  there  for  any 
length  of  time. 


92  DISEASES   OF   THE    RECTUM   AND    ANUS. 

The  distinction  between  an  external  and  an  internal  hgemorrhoid  is 
not,  however,  a  purely  arbitrary  one,  the  one  being  below,  and  the  other 
above  the  external  sphincter.  A  different  set  of  blood-vessels  is  impli- 
cated in  each  case.  An  external  hgemorrhoid  is  a  varicosity  of  an  external 
haemorrhoidal  vein,  and  is,  therefore,  an  affection  of  the  general  venous 
circulation.  An  internal  hgemorrhoid  is  a  varicosity  of  the  middle  or 
internal  haemorrhoidal  veins,  which  are  parts  of  the  visceral  venous 
system.  '  A  glance  at  the  venous  anatomy  of  the  rectum  and  anus  (pages 
14  and  15)  will  show  the  arrangement  of  these  two  sets  of  veins,  and  will 
also  explain  how,  from  tlie  free  anastomosis  which  exists  between  them,  it  is 
improbable  that  one  should  be  affected  without  influencing  the  other  to 
a  greater  or  less  extent,  and  how,  judged  by  this  test  alone,  it  may 
be  impossible  to  tell  whether  a  particular  haemorrhoid  belongs  to  one 
system  or  the  other.  For  practical  purposes,  therefore,  the  first  defini- 
tion is  the  better  one — an  external  haemorrhoid  is  one  originating  outside 
of  the  external  sphincter,  and  an  internal  one  is  within  that  muscle. 
Other  secondary  differences  which  may  arise  from  various  causes  in  the 
development  and  location  of  the  tumors  will  be  considered  later. 

External  HmmorrTioids. — A  person  of  middle  age  who  has  not  at 
some  time  suffered  from  an  external  haemorrhoid  is  indeed  a  gi'eat  rarity, 
so  common  is  this  affection.  In  the  majority  of  cases,  it  is  allowed  to 
run  its  own  course,  and  only  when  the  pain  is  unusually  severe,  or  some 
untoward  accident  has  happened,  does  the  patient  consult  the  surgeon. 
It  is  perhaps  useless  to  seek  for  the  causes  of  a  malady  which  is  so  uni- 
versal beyond  a  few  which  are  well  recognized  and  manifest.  Amongst 
these  are  straining  at  stool,  pregnancy,  affections  of  the  internal  organs 
which  interfere  with  the  return  of  venous  blood,  and  constipation.  Out- 
side of  these  cases  where  a  manifest  cause  exists,  external  haemorrhoids 
will  be  found  amongst  all  classes.  Those  who  smoke  and  those  who  do 
not;  the  high  liver  and  the  abstemious;  the  laborer  and  the  professional 
man;  those  who  stand  and  those  who  sit;  are  all  affected  and  about 
equally. 

An  external  haemorrhoid  may  appear  in  two  different  forms  which 
bear  little  resemblance  to  each  other.  The  first  is  a  small,  round  or 
elongated  venous  tumor;  the  second  is  a  ta^  of  hypertrophied  skin, 
sometimes  improperly  spoken  of  as  a  condyloma.  The  second  is  formed 
from  the  first  by  changes  soon  to  be  described. 

The  external  haemorrhoid  may  arise  in  either  of  two  ways,  by  the 
dilatation  of  a  vein,  or  the  rupture  of  a  vein  and  the  extravasation  of 
blood  into  the  adjacent  tissue.  The  dilatation  may  not  always  be  of  the 
same  character.  In  one  case  it  may  affect  the  whole  calibre  of  the  vessel, 
in  another  it  may  be  in  the  form  of  a  poucli  springing  out  from  one  point 
in  the  circumference.  A  haemorrlioid  resulting  from  the  dilatation  of  a 
vessel  is  of  gradual  formation;  but  it  sometimes  happens,  particularly 
after  a  violent  straining  at  stool,  that  the  patient  will  feel  a  peculiar 


UiKMOBBUOIDS.  93 

aensation  at  the  anus,  and  an  examination  will  reveal  the  presence  of  a 
tense,  bluish,  smooth  tumor,  the  size  of  a  pea  or  a  grape,  situated  just  at 
its  verge.  In  this  cose,  a  previously  dilated  and  weakened  vein  has 
suddenly  given  way,  and  the  tumor  is  the  result  of  the  extravasation  of 
blood. 

Such  a  bloody  tumor  as  this  will  cause  much  pain  and  discomfort, 
preventing  the  patient  from  sitting  down,  or  even  from  going  round  with 
any  ease.  It  may  be  freely  incised  by  transfixing  its  base  with  a  small, 
sharp,  curved  bistoury  and  cutting  outwards,  the  incision  being  in  the 
direction  of  the  radiating  folds  of  the  anus,  and  this  operation  is  sure  to 
give  temporary  relief,  by  allowing  the  escape  of  a  small  clot  of  blood  and 
putting  an  end  to  the  tension  which  is  causing  the  suffering. 

If  the  surgeon  undertake  this  method  of  treatment,  there  are  one  or 
two  hints  which  may  be  of  value.  The  incision  itself  is  extremely  pain- 
ful, and  should  therefore  be  done  with  a  sharp  knife  of  the  form  men- 
tioned; and  it  should  be  done  instantaneously.  Whatever  deliberation 
is  required,  is  better  exercised  before  entering  the  knife.  Again,  care 
should  be  exercised  to  empty  the  clot  entirely  out  of  its  bed,  otherwise  a 
small  wound  remains  which  will  not  readily  heal,  because  the  sac  is  pre- 
vented from  contracting,  and  the  patient  is  obliged  to  wear  a  bandage 
perhaps  for  a  week  or  longer  to  keep  from  soiling  the  linen  with  a  sani- 
ous  discharge.  Under  such  circumstances  also  the  pain  is  but  little 
relieved  by  the  operation.  Again,  I  have  in  a  few  cases  seen  the  incision 
heal  by  primary  intention,  and  the  sac  again  fill  with  blood,  thus  leaving 
the  patient  in  the  same  condition,  as  regards  suffering,  as  before  opera- 
tion. This  is  best  avoided  by  placing  a  shred  of  lint  in  the  cut.  These, 
however,  are  untoward  accidents  which  may  attend  an  insignificant 
operation  which  usually  gives  relief  to  suffering,  and  allows  the  tumor  to 
shrivel  up  and  disappear  except  for  a  small  tag  of  skin  which  may  remain 
and  form  an  external  pile  of  the  second  variety. 

When  left  to  its  own  course,  a  bloody  tumor  of  this  variety  may 
gradually  decrease  in  size  from  the  absorption  of  the  fluid  elements  of 
the  clot,  the  pain  decreasing  at  the  same  time;  and  after  a  week  or  ten 
days  of  discomfort,  it  is  changed  into  a  cutaneous  hajmorrhoid.  Or  the 
opposite  course  may  be  taken,  and  the  tumor  may  show  all  the  signs  of 
an  abscess,  and  finally  rupture  spontaneously  with  the  discharge  of  a 
little  blood  and  pus,  and  with  an  instantaneous  ending  to  a  week  of 
suffering.  For  during  this  acute  inflammatory  process,  the  pain  is  often 
very  severe,  the  discomfort  constant,  and  there  may  be  more  or  less 
febrile  excitement;  all  of  which  will  pjiss  away  the  moment  the  tension 
is  relieved.  The  treatment  of  such  a  case  where  the  knife  is  not  used 
will  be  described  a  little  later. 

To  return  to  the  hsemorrhoid  which  is  due  to  the  varicose  vein,  but 
not  to  the  extravasjition  of  its  contents.  In  such  a  case  there  may  be 
one  considerable  dilatation  which  shall  cause  a  smooth,  round,  bluish 


94  DISEASES   OF    THE    RECTUM    AND    ANUS. 

tumor  the  size  of  a  pea  or  a  grape ;  or  there  may  be  a  number  of  veins  in- 
cluded in  a  new  growth  of  connective  tissue  which  shall  constitute  a  dis- 
tinct, firm,  haemorrhpidal  tumor.  For  these  dilated  pouches  are  in  them- 
selves causes  of  irritation,  and  are  subject  to  irritation  from  without; 
and  as  a  result  an  exudation  takes  place  in  their  vicinity  which  finally 
ends  in  the  production  of  new  tissue.  It  is  thus  easily  understood  why 
on  cutting  into  one  external  hsemorrhoid  a  single  large  clot  will  be  ex- 
posed contained  in  a  distinct  sac;  while  in  another,  several  smaller  clots 
may  be  seen  imbedded  in  the  surface  of  the  section,  and  why  there  is 
more  or  less  connective  tissue  in  the  tumor. 

The  formation  of  such  a  tumor  is  a  gradual  process  due  to  the  con- 
tinuous action  of  the  primary  cause  and  to  subsequent  irritation  from  with- 
out. It  may  go  on  with  little  pain  and  suffering,  so  little  that  the 
patient  will  hardly  care  to  ask  for  relief  ;  and  it  may  undergo  a  spontane- 
ous cure  leaving  m  its  place  only  an  hypertrophied  tag  of  skin.  Gener- 
ally, however,  during  its  course  an  attack  of  acute  inflammation  will  be  ex- 
cited at  some  time,  and  this  is  very  apt  to  bring  the  sufferer  into  the  hands 
of  the  surgeon.  At  such  a  time,  if  the  inflammation  has  occurred  in  a 
fleshy  pile  the  tag  will  be  swollen,  cedematous,  and  exquisitely  sensitive. 
Suppuration  may  occur  in  it  and  a  small  marginal  abscess  and  fistula  be 
the  result.  Or,  if  the  inflammation  has  attacked  a  sanguineous  tumor, 
it  will  be  found  hard  and  swollen  and  painful  to  the  touch.  The  patient 
will  often  say  that  he  has  tried  to  replace  the  little  grape-like  tumor  with- 
in the  bowel,  but  has  been  unable,  though  the  pressure  has  caused  it  to 
disappear  for  the  moment  and  has  given  a  temporary  relief.  This  is  due 
to  emptying  the  vein  of  its  blood,  but  the  blood  returns  the  moment  the 
pressure  is  removed. 

The  pain  is  constant,  often  preventing  sleep  at  night.  The  sufferer 
is  unable  to  sit  or  stand  and  soon  finds  that  he  feels  better  in  the  recum- 
bent posture.  A  motion  of  the  bowels  is  feared  and  therefore  avoided  as 
long  as  possible.  When  after  two  or  three  days  of  constipation  the  call 
can  no  longer  be  delayed,  the  pain  is  gi*eatly  increased.  It  is  astonishing 
how  much  pain  and  constitutional  disturbance  such  an  apparently  trivial 
thing  may  cause. 

Such  as  an  attack  in  a  sanguineous  haemorrhoid  may  terminate  in 
three  ways:  by  resolution,  by  induration,  and  by  suppuration.  In  the 
former  case  the  resolution  may  be  complete  especially  when  the  inflam- 
mation has  been  of  moderate  intensity,  and  no  trace  of  the  tumor  may  re- 
main, or  a  cutaneous  tag  may  be  left  to  mark  its  former  site.  When  the  in- 
flammation assumes  a  chronic  type,  and  the  tumor  becomes  cedematous, 
and  is  still  somewhat  painful  on  pressure  or  during  defecation,  thouglmot 
to  such  a  degree  as  during  the  acute  stage,  the  inflammation  is  said  to 
have  terminated  in  induration.  Such  a  tumor  is  always  liable  on  slight 
provocation  to   a  fresh  attack   of  inflammation.      When  suppuration 


H^MOKRHOIDS.  '  95 

occurs,  the  tumor  discharges  its  pus  and  then  shrivels  up  and  becomes  a 
cutaneous  tag. 

Treatment. — The  surgeon  will  seldom  be  called  upon  to  treat  a  case 
of  external  haemorrhoids  unless  during  an  attack  of  acute  inflammation; 
for  at  other  times  the  annoyance  caused  by  them  is  comparatively  trivial. 
A  cutaneous  tag  which  is  quiescent  may  as  well  be  left  undisturbed  by 
the  knife  or  scissors;  for  the  removal  of  it  will  not  infrequently  cause  an 
amount  of  suffering  disproportionate  to  the  benefit  gained.  The  whole 
thought  of  the  surgeon  may  then  be  turned  first  to  the  prevention  and 
second  to  the  relief  of  an  attack  of  inflammation.  The  means  of  preven- 
tion are  very  simple  and  yet  very  effectual.  They  consist  in  the  avoid- 
ance of  excess  in  eating  or  drinking  and  in  perfect  regularity  in  defeca- 
tion; for  ina  j>erson  affected  with  external  haemorrhoids  a  single  heavy  meal 
at  an  unusual  hour,  an  evening  spent  in  smoking  and  drinking,  or,  worst 
of  all,  the  neglect  to  have  a  motion  of  the  bowels  for  a  single  day,  will  give 
rise  to  a  sensation  of  heat,  pressure,  and  itching  about  the  anus,  which 
warns  him  that  trouble  has  commenced.  Even  under  such  circumstances 
the  attack  may  be  aborted  by  rest  in  the  recumbent  attitude,  a  light  diet, 
abstinence  from  wine  or  liquor  of  any  kind,  and  a  laxative,  preferably  one 
of  the  mineral  waters,  repeated  every  night  for  three  or  four  days. 

Should  the  attack  go  on  and  inflammation  be  actually  excited,  more 
active  treatment  will  be  required,  and  this  may  be  either  operative  or 
medicinal.  It  is  my  own  practice  to  try  the  latter  first,  and  if  it  does  not 
succeed,  resort  to  the  former.  The  medicinal  treatment  consists  in  keep- 
ing the  sufferer  on  the  bed  or  lounge,  and  applying  a  small  bladder 
of  pounded  ice  to  the  part.'  This  is  generally  very  grateful  to  the 
patient  and  very  effectual — much  more  so  than  warm  poultices  or  appli- 
cations  of  belladonna  and  opium;  but  should  it  not  prove  so,  the  latter 
may  be  tried.  A  good  formula  is  equal  parts  of  the  extracts  of  bella- 
donna and  opium  smeared  freely  over  the  anus.  In  most  cases  the 
attack  will  subside  after  forty-eight  hours  of  this  treatment,  and  the  use 
of  a  daily  laxative;  but  should  it  not,  a  sanguineus  tumor  may  be 
incised  in  the  manner  already  described,  and  a  cutaneous  tag  may  be 
seized  with  a  sharp  forceps  and  quickly  snipped  off  with  the  scissors. 
Ether  is  not  generally  necessary  for  this  operation,  which,  though  very 
painful,  requires  but  a  moment;  and  I  have  generally  found  that 
attempts  at  local  anaasthesia  with  the  ether  spray  were  very  delusive  in 
this  part  of  the  body.  If  ether  be  employed  at  all,  it  is  much  better  to 
take  advantage  of  the  primary  anaesthesia  produced  by  the  first  few  inhal- 
ations, the  patient  holding  the  towel  or  bottle  in  his  or  her  own  hand. 
This  is  a  favorite  procedure  of  my  own  in  this  and  many  other  opera- 
tions about  the  anus,  and  one  which  I  cannot  too  strongly  recommend. 

'  Nothing  is  80  convenient  for  this  purpose  or  causes  as  little  pain  as  the  rubber 
baudruche.  which  may  now  be  procured  at  any  druggist's. 


96  DISEASES   OF   THE   KECTTJM    AND    ANUS. 

The  only  caution  necessary  in  cutting  off  an  external  haemorrlioid  is 
to  remove  neither  too  much  nor  too  little  tissue.  If  too  much  be  re- 
moved, the  wound-  will  take  a  long  time  to  heal,  and  if  several  tumors  be 
removed,  contraction  to  a  disagreeable  extent  may  follow;  if  too  little,  a 
tag  of  skin  will  still  remain  after  cicatrization  and  shrinking,  and, 
although  this  might  be  considered  a  matter  of  no  importance  in  a  male 
patient,  I  have  seen  ladies  who  did  not  so  consider  it. 

Internal  Hmnorrhoids. — External  haemorrhoids  were  described  as 
varicosities  of  the  external  hsemorrhoidal  veins;  and  internal  haemorrhoids 
may  also  be  similarly  defined  as  varicosities  of  the  middle  and  superior 
haemorrhoidal  veins,  but  they  are  more  than  this.  An  internal  hasmor- 
rhoid  is  often  an  arterial  tumor,  as  well  as  a  venous,  and  the  arteries 
may  be  of  large  size.  Occasionally  one  will  be  met  as  large  as  the  radial. 
In  describing  these  tumors,  we  shall  follow  the  division  laid  down  by 
AUingham  into  capillary,  arterial,  and  venous. 

The  capillary  hemorrhoid  is  in  reality  an  erectile  tumor,  composed  of 
the  terminal  branches  of  the  arteries  and  veins  Jind  of  the  capillaries 
which  join  them.  This  form  of  tumor  is  never  of  large  size,  and  never 
projects  very  far  into  the  cavity  of  the  rectum.  To  the  naked  eye  and 
under  the  microscope  they  strongly  resemble  an  arterial  naevus.  They 
maybe  situated  high  up  in  the  rectum  or  low  down  by  the  sphincter; 
their  surface  is  granular,  and  the  membrane  covering  them  is  always  of 
extreme  thinness.  This  accounts  for  the  chief  symptom  which  distin- 
guishes them  clinically  from  the  other  varieties — the  free  arterial  haemor- 
rhage which  follows  the  slightest  bruising  of  their  surface  even  in  the  act 
of  defecation.  Such  a  tumor  never  appears  outside  of  the  anus  unless 
accompanied  by  some  other  rectal  affection,  but  it  may  sometimes  be  seen 
by  a  careful  pulling  open  of  the  sphincter  with  the  fingers,  and  from 
some  part  of  its  strawberry-like  surface  there  is  pretty  sure  to  be  a  jet  of 
arterial  blood,  covamgper  saltern.  The  disturbance  caused  by  the  gentlest 
examination  is  sufficient  to  start  this  bleeding,  and  it  almost  always 
occurs  at  defecation.  This  is  the  form  of  haemorrhoid  to  which  the  name 
of  "  bleeding  "  most  properly  applies.  In  my  own  experience  it  is  not  as 
frequently  met  with  as  the  varieties  to  be  described  later;  and  this  prob- 
ably for  the  reason  that  after  existing  for  a  longer  or  shorter  period  in 
this  form  it  is  changed  into  one  of  the  others:  and  that  patients  do  not 
seek  relief  till  after  such  change  has  occurred.  After  a  time,  the 
mucous  membrane  covering  such  a  tumor  becomes  thickened,  and  as  a 
result  of  repeated  irritation,  there  is  an  increase  in  the  submucous  tissue. 
The  haemorrhage  decreases  in  frequency  and  finally  ceases  as  the  capilla- 
ries become  obliterated  by  the  increase  in  the  connective  tissue,  and  the 
capillary  tumor  is  succeeded  by  the  arterial  or  the  venous  one. 

The  one  symptom  of  a  capillary  haemorrhoid  is  the  daily  haemorrhage; 
and  as  this  haemorrhage  occurs  at  the  time  of  defecation,  and  there  is  no 
pain  at  any  time,  the  patient  may  be  entirely  ignorant  of  the  fact  that 


I 

HiKMORBHOIDS.  97 

blood  is  daily  lost.  This  is  particularly  the  case  with  the  class  of  patients 
seen  in  public  practice  who  give  little  attention  to  themselves.  In  the 
hiirlicr  walks  of  life  such  a  loss  of  blood  seldom  occurs  without  the 
knowledge  of  the  patient;  but  unfortunately  it  is  often  disregarded,  es- 
jwcially  in  women  who  are  in  the  habit  of  losing  blood  at  every  menstrual 
turn  and  who  always  shrink  from  an  examination. 

It  is  not  necessary  to  relate  in  detail  the  train  of  constitutional  symp- 
toms which  may  follow  the  daily  loss  of  a  considerable  quantity  of  arterial 
blood.  The  anaemic  look,  the  disturbance  of  the  heart's  action,  the 
troubles  with  the  digestive  apparatus  and  with  the  sexual  organs,  the 
cessation  of  menstruation,  are  all  well  known.  But  it  is  curious  that,  as 
in  a  recent  case  in  my  own  practice,  a  very  intelligent  medical  man  who 
understood  perfectly  his  own  condition,  should  allow  himself  to  be 
brought  to  a  state  of  profound  anaemia  by  a  little  haemorrhoid  of  this 
variety  rather  than  have  anything  done  for  himself.  In  his  case  a  single 
application  of  nitric  acid  to  the  bleeding  surface  worked  a  cure  which 
has  lasted  for  several  years. 

The  arterial  hcemorrhoid. — In  this  form  of  tumor  the  capillary  net- 
work has  disappeared  and  in  its  place  is  found  a  mass  of  freely  anastomos- 
ing arteries  and  veins  bound  together  by  connective  tissue.  The  arteries 
and  the  veins  are  tortuous,  often  varicose  and  dilated  into  sacs  and 
pouches,  and  the  arteries  may  be  of  large  size,  especially  the  one  which 
enters  at  the  base  of  the  tumor,  the  pulsations  of  which  may  often  be 
distinctly  felt  by  the  finger.  Such  a  tumor  is  often  of  considerable  size; 
it  is  firm  to  the  touch  and  smooth;  it  is  liable  to  inflammation,  erosion, 
haemorrhage,  and  prolapse.  The  haemorrhage  Avhich  occurs  is  arterial  in 
character,  and  apt  to  be  abundant.  When  the  haemorrhoid  has  gained  a 
suflicient  size  to  become  prolapsed  in  the  act  of  defecation,  the  patient 
suffers  the  usual  symptoms  of  the  haemorrhoidal  state.  If  the  sphincter 
be  not  tight  enough  to  strangulate  the  mass  after  it  has  come  out  of  the 
body,  the  pain  will  not  be  very  severe  and  the  patient  will  return  the 
tumor  by  a  little  gentle  pressure  and  manipulation. 

The  venous  hcBinorrlioid. — This  form  of  haemorrhoid  may  result  from 
either  of  those  already  named  or  it  may  arise  de  novo.  It  consists  at  first 
of  a  simple  dilatation  of  the  large  veins  beneath  the  mucous  membrane  of 
the  rectum;  later  these  veins  undergo  certain  changes  due  to  the  hyper- 
trophy and  induration  of  the  mucous  membrane  and  submucous  connec- 
tive tissue,  until  finally  a  large,  bluish,  hard  tumor  is  formed  which 
is  smooth  to  the  touch,  comes  out  of  the  body  on  defecation,  and  is 
covered  by  a  mucous  membi-ane  which  has  assumed  a  partially  cutaneous 
character  from  exposure. 

The  three  varieties  of  internal  ha;morrhoids  thus  described  may  all  be 
present  in  the  same  person,  and  each  be  distinguishable  from  the  other. 
In  other  cases  the  line  of  distinction  may  not  be  so  well  marked.  A 
venous  haemorrhoid  mav  contain  a  considerable  number  of  arteries  and 


98  DISEASES    OF   THE    KECTUM    AND    ANUS. 

may  bleed  per  saltern,  and  it  is  not  certain  that  an  arterial  haemorrhoid 
is  always  a  later  stage  of  the  capillary  variety.  But  the  three  forms  are 
well  marked  andmust  be  distinguished  from  each  other  in  the  matter  of 
treatment. 

Symptoms. — Usually  the  first  symptom  of  internal  haemorrhoids  is  the 
loss  of  blood  during  defecation  to  which  reference  has  already  been  made. 
This  may  be  present  for  a  long  time  before  any  other  symptom  is  no- 
ticed by  the  patient  except  perhaps  an  occasional  feeling  of  discomfort 
in  the  rectum.  Pain  is  absent  until  the  tumor  begins  to  descend  within 
the  grasp  of  the  sphincter  and  appears  at  the  anus  at  each  act  of  defeca- 
tion. If  the  sphincter  be  firm  and  strong,  the  pain  may  be  very  severe 
and  the  tumor  may  become  strangulated,  but  after  the  disease  has  existed 
for  any  great  length  of  time,  and  especially  in  persons  past  middle  life, 
there  is  apt  to  be  alossof'power  in  the  muscle  which,  though  it  facilitates 
prolapse,  decreases  the  pain  attendant  upon  it. 

In  ordinary  cases,  tlie  patient  will  reduce  the  tumors  when  they  come 
down  on  defecation.  They  may,  however,  become  strangulated,  and  be 
entirely  beyond  the  patient's  power  of  manipulation.  In  such  a  case,  after 
a  period  of  rest,  and  after  the  relief  which  may  follow  a  spontaneous  es- 
cape of  blood  from  the  over-distended  vessels,  the  haemorrhoids  may  return 
of  themselves  or  be  put  back  by  the  patient. 

If  the  strangulation  be  more  intense,  gangrene  may  set  in  and  a 
part  of  the  mass  may  slough;  or  a  part  may  suppurate  and  pus  be  dis- 
charged. Under  these  circumstances  there  will  be  great  pain  and  more 
or  less  constitutional  disturbance,  with  fever  and  loss  of  appetite.  The 
gangrene  is  very  evident  to  the  eye  from  the  greenish  or  blackish  color 
and  foetid  odor  of  the  part,  and  is  rather  a  favorable  termination  to  the 
trouble  as  it  generally  results  in  a  radical  cure; 

Diagnosis. — It  is  not  always  an  easy  matter  to  discover  an  internal 
haemorrhoid,  even  though  it  be  far  enough  advanced  to  cause  haemor- 
rhage and  more  or  less  uneasiness.  When  it  has  become  hard,  it  may 
be  detected  by  the  accustomed  finger  in  a  simple  digital  examination, 
but  when  soft  and  not  over-distended,  it  may  escape  detection.  An 
examination  should  be  made  directly  after  the  rectum  has  been  emptied 
by  an  enema  of  warm  water,  when  the  water  and  the  straining  have 
brought  it  into  prominence,  and  should  be  made  with  Van  Buren's  spec- 
ulum. Under  these  circumstances,  it  may  generally  be  brought  plainly 
into  view.  An  examination  in  a  case  of  internal  haemorrhoids  should 
never  end  at  the  finding  of  the  tumor.  An  inch  or  so  higher  up  there  may 
be  a  stricture,  malignant  or  simple,  which  has  given  no  sign  of  its  pres- 
ence except  the  haemorrhoids,  and  this  is  not  a  good  thing  to  overlook. 

Treatment. — The  treatment  of  this  most  common  and  distressing 
malady  may  with  advantage  be  considered  under  two  different  heads — (a) 
palliative,  (Z»)  radical.   • 

(a)  The  palliative  treatment  of  internal  hcemorrJioids.     In  spite  of 


Hii!:MORRHoii>e.  99 

all  that  the  surgeon  may  say  to  his  patient  of  the  advantages 
of  a  radical  cure,  and  the  safety  and  facility  with  which  it  may 
be  accomplished,  he  will  still  have  many  more  chances  in  the  way  of 
palliation  than  will  fall  to  him  of  using  the  knife.  It  is,  therefore,  of 
great  advantage  to  know  what  can  be  done  for  a  timid  and  reluctant 
sufferer  without  the  knife;  and,  indeed,  most  patients  may  be  made 
greatly  more  comfortable  without  any  surgical  interference  whatever. 

The  first  thing  to  be  done  is  to  secure  a  daily  natural  evacuation  of 
bowels,  and  this  without  medicine,  if  possible.  The  diet  should  be  plain 
and  abundant.  Highly  seasoned  meats,  gravies,  salads,  old  cheese,  etc., 
all  alcoholic  drinks,  and  anything  approaching  excess  in  tobacco,  should 
be  strictly  interdicted.  If  the  bowels  do  not  act  daily  with  this  diet,  and 
with  regularity  in  the  time  of  going  to  the  closet,  a  laxative  must  be 
added,  and  this  may  be  either  in  the  form  of  a  mineral  water  in  the 
morning,  or  of  a  small  dose  of  compound  licorice  powder  at  night. 

This  powder  may  now  be  bought  under  that  name  at  most  drug  stores. 
The  formula  is,  however,  appended  for  the  convenience  of  any  who  may 
desire  it:  , 

}}.  Fol.  sennjK • 2  parts. 

Had.  liquiritise 2  parts. 

Fruct.  foeniculi  pulv 1  part. 

Sulphuris  depurati 1  part. 

Sacch.  pulv 6  pai'ts. 

If  the  haemorrhoids  are  in  the  habit  of  coming  down  when  the  patient 
hiis  a  passage,  he  must  accustom  himself  for  a  time  to  the  use  of  a  bed- 
pan, and  to  having  his  passages  while  in  the  horizontal  position.  This 
will  be  considered  a  very  objectionable  remedy  by  most;  but  it  is  one 
from  which  great  benefit  will  be  derived. 

The  other  treatment  is  local,  and  consists  mainly  in  the  use  of 
astringents  and  of  cold.  After  each  passage,  the  bowel  should  be 
injected  with  cold  water.  Even  ice- water  will  do  no  harm.  The  quan- 
tity should  not  exceed  four  ounces,  and  if  the  case  is  one  attended  with 
bleeding,  this  will  be  found  a  most  valuable  means  of  combating  that 
symptom.  The  number  of  astringents  which  have  been  recommended  for 
use  under  the  circumstances  wo  are  now  considering  is  very  large.  I 
shall  content  myself  with  naming  one,  the  subsulphate  of  iron,  which 
combines  the  advantages  of  all  the  others.  This  may  be  applied  in  the 
form  of  an  ointment  (  3  i.—  3  i.)  to  the  hsemorrhoids  when  prolapsed,  or 
may  be  given  in  the  form  of  a  suppository  (2  gr.)  and  allowed  to 
remain  in  the  rectum  over  night.  It  will  be  found  to  act  simply  as  an 
astringent,  causing  no  pain,  and  destroying  no  tissue. 

By  these  means,  when  followed  with  care  and  patience,  the  worst 
case  of  haemorrhoids  may  be  greatly  improved,  and  wiien  the  sufferer 
will  not  submit  to  curative  treatment,  or  when,  from  any  reason,  opera- 


100  DISEASES    OF   THE    KECTUM    AND    ANUS. 

tive  interference  is  contra-indicated,  they  should  always  be  tried.  Al- 
though they 'are  given  simply  as  palliative  measures,  and  should  be 
considered  as  such,  I  have  had  some  cases  where,  after  a  few  weeks  of 
this  treatment,  the  patients  believed  themselves  cured,  and  were,  at  all 
events,  so  far  relieved  as  to  disappear  from  observation. 

Treatment  of  strangulation. — The  practitioner  may  at  any  time  be 
called  upon  to  treat  this  complication  of  internal  haemorrhoids,  and  the 
condition  is  an  exceedingly  painful  one.  He  will  generally  find  his 
patient  in  bed  complaining  that  his  piles  are  *'down,"  and  that  he  has 
been  unable  to  replace  them.  The  prolapse  may  have  occurred  at  the  time 
of  defecation,  or  during  a  momentary  mental  excitement  or  physical  effort. 
On  examination,  the  anus  will  be  seen  to  be  surrounded  with  a  mass  of 
haemorrhoids  which  are  swollen,  congested,  livid,  and  more  or  less 
oedematous,  and  any  attempt  to  replace  them  will  cause  exquisite  pain. 
This  is  an  excellent  opportunity  for  inducing  the  sufferer  to  submit  to  a 
radical  operation,  and  should  consent  be  gained,  ether  may  be  given,  and 
the  usual  operation,  by  the  ligature,  be  at  once  performed.  The  opera- 
tion, under  these  circumstances,  does  not  seem  to  be  contra-indicated, 
and  I  have  never  had  occasion  to  regret  performing  it. 

But  should  an  operation  be  refused,  the  mass  must  be  reduced.  The 
patient  shoiild  be  turned  on  the  face,  with  a  hard  pillow  under  the  pelvis 
to  raise  the  buttocks  and  allow  of  gravitation  of  the  abdominal  contents 
away  from  the  rectum.  The  mass  should  then  be  well  smeared  with 
olive  oil,  and  a  gentle  effort  made  to  reduce  it  by  the  taxis.  This  may 
sometimes  be  done  by  introducing  one  finger  into  the  anus  and  exerting 
pressure  with  the  others,  gradually  forcing  the  tumors,  one  by  one, 
within  the  bowel;  at  other  times,  the  mass  may  be  replaced  by  a  firm 
and  continuous  pressure,  with  the  bulbs  of  all  the  fingers  directly  upon  it, 
till  the  blood  has  been  crowded  back,  and  the  diminished  piles  slip  up 
together.  Much  gentleness  is  required  for  this  manoeuvre,  which  is  a 
very  painful  one  under  any  circumstances,  and  one  man  may  succeed 
where  another  would  fail. 

At  times,  however,  replacement  by  the  taxis  is  impossible.  Under 
such  circumstances,  it  is  a  not  uncommon  practice  to  resort  to  leeches; 
and  though  I  have  never  done  it,  I  have  seen  it  almost  immediately  suc- 
cessful with  others;  and  the  patient  himself  will  assure  you  that,  if  the 
piles  would  only  bleed,  they  could  be  easily  reduced.  It  is  better, 
however,  to  apply  cold,  and  to  leave  the  patient  in  bed  on  his  face,  with 
the  buttocks  raised.  The  cold  should  be  in  the  form  of  an  ice-bag, 
and  this  will  almost  certainly  give  relief  to  suffering,  and  so.  reduce 
the  oedematous  swelling  as  to  render  reduction  possible  on  a  second 
attempt.  Should  this  also  fail,  there  is  nothing  to  do  but  to  wait  for  the 
condition  to  subside  under  the  use  of  cold  and  applications  of  belladonna 
and  opium  in  the  form  of  a  soft  ointment,  with  rest  in  the  position 
named,  and  the  administration  of  laxatives.     After  forty-eight  hours  of 


H£MOBBHOID8.  101 

this  treatment,  the  patient  will  generally  succeed  by  himself  in  reducing 
the  mass. 

(b.)  Curative  Treatment. — Before  recommending  anything  in  the  way 
of  a  surgical  operation,  the  surgeon  must  consider  whether  the  case  before 
him  is  one  in  which  such  a  procedure  is  justifiable,  and  this  brings  us  to 
the  consideration  of  what  have  been  called  symptomatic  haemorrhoids,  as 
distinguished  from  those  which  are  apparently  idiopathic. 

Internal  hajmorrhoids  may  be  symptomatic  of  disease  in  a  number  of 
the  viscera.  They  often  indicate  structural  changes  in  the  wall  of  the 
rectum  itself  at  a  higher  point,  such  as  malignant  and  non-malignant 
stricture  ;  and  under  such  circumstances,  whatever  is  done  in  the  way  of 
relief  must  be  done  to  the  stricture,  and  not  to  the  haemorrhoids. 
Again,  they  are  often  secondary  to  disease  of  the  bladder,  to  enlarged 
prostate,  or  to  stricture  of  the  urethra ;  and  in  these  cases  where  it  is 
possible  to  remove  the  cause  it  must  always  be  done.  If  haemorrhoids 
are  dependent  upon  a  calculus,  or  a  stricture  of  the  urethra,  they  will 
disappear  when  these  affections  are  cured.  I  was  consulted  not  long 
since  by  a  brother  practitioner  in  regards  to  a  very  typical  external 
sanguineous  haemorrhoid — the  size  of  a  large  pea— on  the  person  of  his 
four-year  old  child.  The  child  had  an  adherent  prepuce,  and  the  pile 
was  the  result  of  the  straining.  The  ordinary  operation  of  circumcision 
cured  the  haemorrhoid.  A  man  with  enlarged  prostate  is  never  a  very 
desirable  subject  for  a  surgical  operation,  and  if  such  a  man's  hasmor- 
rhoids  can  be  rendered  endurable  by  the  palliative  treatment  already  de- 
Bcribed,  the  better  way  will  be  not  to  use  the  knife. 

In  women  haemorroids  often  depend  upon  disease  of  the  uterus  ;  and 
in  every  female  patient  this  dependence  should  be  carefully  inquired  into, 
and  if  found,  removed  before  operation.  The  operator  in  rectal  sur- 
gery may  save  himself  much  discredit,  by  postponing  his  operation  for 
piles  till  his  patient  has  been  cured  of  a  uterine  misplacement  or  catarrh; 
for,  as  a  rule,  the  co-existence  of  the  latter  diseases  will  prevent  a  favor- 
able issue  to  the  operation.  Either  the  wounds  will  not  heal  readily,  or 
the  liaemorrhoids  will  speedily  return.  It  will  occasionally  happen  that 
a  pregnant  woman  will  suffer  so  severely  from  this  complication  as  to  de- 
mand surgical  aid.  Though  it  is  better  not  to  operate,  except  in  a  case 
where  the  haemorrhage  or  the  pain  render  it  unavoidable,  still  pregnancy 
is  not  an  absolute  barrier  to  surgical  interference  in  this  more  than  in 
many  other  affections. 

Haemorrhoids  may  also  be  symptomatic  of  disease  of  the  liver,  kidney, 
heart,  or  lungs.  There  are  few  liver  affections  which  need  prevent  oper- 
ative interference  in  a  bad  case,  but  such  interference  should  be  preceded 
by  general  treatment  pointing  towards  relief  of  the  hepatic  circulation. 
An  excess  of  alcohol  in  the  daily  diet  should  be  stopped,  and  a  blue  pill 
may  be  given  with  advantage  every  other  day  for  a  week  before  the  •oper- 
ation.    Affections  of  the  lungs,  except  in  a  very  advanced  stage,  need 


102  DISEASES    OF   TH^    KECTUM    AND    ANUS. 

not  prevent  an  operation.  The  condition  which  most  positively  stays 
the  hand  of  the  operator  is  that  of  albuminuria,,  whether  dependent  upon 
heart  or  kidney. 

Having  decided  to  attempt  a  radical  cure,  the  surgeon  finds  himself 
embarrassed  with  the  number  of  operative  procedures  from  which  he  may 
choose.  It  is  safe  to  say  that  no  one  operation  is  the  best  in  all  cases,  and 
I  shall  make  no  attempt  even  to  enumerate  all  of  those  which  have,  at 
different  times,  been  advocated,  but  shall  describe  several  which  are  to 
be  relied  upon,  and  which,  together,  will  cover  every  case. 

The  Application  of  Caustics. — Chief  among  the  caustics  used  for  this 
purpose  are  nitric  acid,  pure  carbolic  acid,  and  Vienna  paste.  The  capil- 
lary haemorrhoid  may  be  cured  by  painting  it  once  or  twice  with  pure 
nitric  or  carbolic  acid  ;  but  large  and  old  haemorrhoids  are  not  curable 
by  this  means,  though  the  haemorrhage  from  them  may  be  stopped,  and 
for  a  time  they  may  cease  to  prolapse.  When  used  upon  a  capillary 
growth,  a  speculum  must  be  introduced.  If  used  in  a  case  of  large 
tumors,  they  must  first  be  brought  outside  of  the  body,  carefully  dried, 
and  then  thoroughly  covered  with  the  acid,  applied  with  a  small 
stick.  The  end  of  a  match  makes  an  excellent  brush.  The  tumors 
should  then  be  well  oiled  and  replaced.  The  application  is  not  painful, 
unless  the  acid  is  applied  to  the  wrong  surface,  viz.,  the  skin. 

I  have  used  this  plan  of  treatment  in  many  cases ;  have  seen  an 
exhausting  haemorrhage  from  a  capillary  tumor  stopped  forever  by  a 
single  application,  and  have  benefited  old  cases  to  an  extent  which  con- 
vinced the  patients  they  were  radically  cured  in  spite  of  my  own  skepti- 
cism; but  it  is  never  safe  to  promise  anything  more  than  temporary  re- 
lief by  this  means.  The  capillary  tumor  is  very  likely  to  subsequently 
become  the  larger  arterial  one ;  and  the  old  and  large  haemorrhoid  is 
more  than  likely  to  become  prolapsed  at  some  future  date:  so  that  I  no 
longer  use  it  in  these  latter  cases  when  the  patient  will  permit  me  to  fol- 
low my  own  judgment. 

There  is  one  danger  in  the  application  of  a  strong  acid  to  an  old  pro- 
lapsing haemorrhoid,  and  that  is,  the  occurrence  of  a  profuse  secondary 
haemorrhage  when  the  slough  separates.  Such  an  accident  is  not  com- 
mon, but  it  may  be  a  fatal  one,  and  it  happens  just  often  enough  to 
worry  the  surgeon  in  every  case  in  which  he  has  employed  this  method 
in  an  old  and  debilitated  subject. 

The  Vienna  paste  is  a  much  more  powerful  caustic  than  nitric  acid, 
and  its  application  to  the  surface  of  a  haemorrhoid  is  very  painful. 
This  and  the  amount  of  tissue  destroyed  by  it  are  the  two  great  objec- 
tions to  its  use.  It  has  been  employed  to  produce  deep,  linear,  radiating 
cicatrices,  each  cicatrix  running  from  the  centre  of  the  anus  over  the  top 
of  a  prolapsed  hsemorrhoid;  and  three  or  four  such  cauterizations  will 
undoubtedly  cure  an  ordinary  case  of  piles;  but  the  Paquelin  cautery  will 


HAEMORRHOIDS.  103 

do  it  much  better,  and  if  the  patient  will  submit  to  the  latter,  he  will 
submit  to  something  better  still,  and  that  is  the  ligature. 

Treatment  by  Injection. — The  treatment  of  haemorrhoids  by  injection 
of  certain  substances,  chief  of  which  is  carbolic  acid,  may  now,  I  believe, 
be  accepted  as  a  surgical  procedure  of  a  certain  definite  value,  and  one 
worthy  of  a  place  among  the  recognized  means  of  cure  at  our  command. 
Originating  as  it  did  among  the  quacks,  it  has  been  looked  upon  with 
suspicion,  and  its  adoption  by  the  profession  has  been  followed  by  the 
accidents  which  generally  attend  a  new  remedy  before  its  applicability  is 
fully  understood;  but  this  does  not  diminish  its  real  value. 

The  following  four  cases,  selected  from  dispensary  and  private  prac- 
tice in  which  this  plan  of  treatment  has  been  adopted,  will  illustrate 
some  of  its  advantages  and  disadvantages. 

Case  VI. — Male.  Age,  thirty-nine.  This  was  an^  ordinary  case  of 
prolapsing  internal  haemorrhoids  of  about  six  months'  duration  in  an 
otherwise  healthy  man.  The  tumors  were  well  developed,  bled  freely  at 
each  motion  of  the  bowels,  and  were  usually  reduced  by  the  patient  with- 
out much  difficulty.  In  the  course  of  three  months  four  injections  of 
carbolic  acid  were  made  into  four  separate  tumors.  Only  one  of  them 
was  followed  by  any  pain  or  soreness,  and  this  not  very  marked  in  charac- 
ter; and  after  three  months  the  man  was  discharged  cured,  there  being 
no  longer  any  bleeding  or  descent  of  the  haemorrhoids  at  defecation. 
The  man,  who  was  a  fireman,  was  at  no  time  during  the  treatment  nn- 
able  to  attend  to  the  active  duties  of  the  service. 

Case  VII. — Male.  Age,  thirty-eight.  In  this  patient  anything  like 
a  cutting  operation  was  out  of  the  question.  He  had  been  a  hard 
drinker  for  years,  and  was  suffering  from  phthisis,  cirrhosis  of  the  liver, 
and  albuminuria.  The  haemorrhoids  were  of  long  standing;  the  whole 
circle  of  mucous  membrane  prolapsed  with  them;  and  the  sphincter  had 
lost  its  contractile  power.  The  man  was  under  treatment  three  months, 
and  during  that  time  six  injections  of  carbolic  acid  were  made,  and  each 
one  was  followed  by  more  or  less  pain  and  by  sloughing  of  the  haemorrhoid. 
The  pain  was  not,  however,  so  great  as  to  counterbalance  the  relief  the 
patient  experienced  from  the  cessation  of  the  bleeding  and  the  decrease 
in  the  protrusion,  and  the  treatment  was  gladly  persisted  in  by  him,  till 
in  the  end  he  considered  himself  as  cured  and  ceased  to  attend.  I  have 
no  doubt  that  in  this  case  the  sloughing  of  the  tumor,  which  each  time 
left  a  dirty  sore  after  the  introduction  of  the  acid,  was  directly  due  to  the 
patient's  condition;  but  he  was  sustained  with  generous  diet  and  suitable 
tonics,  and,  as  I  say,  did  very  well — much  better  than  he  would  have 
done  by  any  other  plan  of  treatment  which  it  was  safe  to  try;  and,  but 
for  it,  I  should  have  confined  myself  strictly  to  palliative  measures. 

Case  VIII. — Male.  Age,  fifty-two.  General  health  excellent.  Haem- 
orrhoids well-developed  and  prolapsing.  Having  had  considerable  experi- 
ence with  this  method  of  treatment  by  this  time  in  dispensary  practice, 


104  DISEASES    OF    THE    RECTUM:    AND    ANUS. 

I  ventured  to  try  it  in  a  private  patient,  and  to  promise  an  easy  and 
painless  cure.  A  single  injection  was  tlierefore  made,  and  for  the  first 
forty-eight  hours  there  was  little  trouble;  but  at  the  end  of  that  time  I 
received  a  telegram  from  the  gentleman  that  he  was  suffering  great  and 
constantly  increasing  pain — he  having  left  me  on  the  day  following  the 
injection  to  return  to  his  home  in  a  neighboring  city.  I  went  to  him 
and  found,  to  my  disgust,  that  the  injection  had  in  his  case  also  caused  a 
slough,  and  that  he  was  suffering  intense  pain  at  each  act  of  defecation. 
Suitable  treatment  with  laxatives  and  anodyne  suppositories  was  at  once 
instituted,  but  his  sufferings  continued  for  many  days,  and  he  finally 
went  off  to  the  mountains  where  he  remained  till  the  ulceration  had 
healed.  Needless  to  say  he  refused  to  continue  this  "  painless  "  method 
of  cure,  and  I  lost  my  patient  and  not  a  little  reputation,  the  man  being 
rich  and  influential. 

Case  IX. — Male.  Age,  fifty-three.  Also  a  private  patient,  and  in 
fair  general  condition,  but  with  old  and  severe  haemorrhoids  and 
partial  prolapse,  and  weakening  of  the  sphincter.  I  was  first  called  to 
see  him  in  the  night  when  he  was  suffering  from  strangulation  of  the 
entire  mass,  and  a  week  later  I  began  the  use  of  the  acid.  This  was  fol- 
lowed very  cautiously  and  with  abundant  intervals  of  rest  after  each 
injection,  and  in  a  very  short  time  the  relief  was  very  apparent  in  the 
diminution  of  the  size  of  the  protrusion.  There  was  no  pain  at  any  time 
during  the  treatment,  and  only  a  slight  nipping  sensation  for  an  hour  or 
so  after  each  injection.  In  the  end  he  was  entirely  cured,  all  haemor- 
rhage and  protrusion  of  the  tumors  having  ceased,  though  the  anus  was 
still  surrounded  by  the  redundant  circle  of  half  skin  and  half  mucous 
membrane  which  remained  from  the  former  condition  of  prolapse. 

Here  then  was  an  old  case  of  large  prolapsing  haemorrhoids  in  a  pri- 
vate patient  who  would  submit  to  nothing  which  he  considered  as  surgical 
treatment,  apparently  cured  without  any  pain,  without  any  of  the  usual 
accessories  of  an  operation,  and  without  a  single  day's  detention  from  his 
ordinary  pursuits — a  result  for  which  surgery  has  been  waiting  a  long 
time.  I  say  apparently  cured,  for  the  one  doubt  which  remains  in  my 
own  mind  regarding  this  treatment  is  as  to  the  perma7ie?icy  of  the  cure. 
This  I  have  not  as  yet  had  time  to  test.  I  have  seen  nothing  to  make 
me  doubt  its  being  permanent;  and  considering  what  Vidal  has  accom- 
plished with  injections  in  cases  of  long-standing  and  extensive  pro- 
lapse, I  see  no  reason  why  it  should  not  be  permanent;  but  I  have  not  as. 
yet  had  a  chance  to  examine  any  of  my  own  cases  after  an  interval  of 
years  which  is  the  only  way  of  positively  deciding  the  question. 

Beginning  this  plan  of  treatment,  as  I  did,  without  very  much  cenfi- 
dence  in  it  and  with  the  fear  of  causing  great  pain  and  perhaps  dangerous 
sloughing  constantly  before  me,  I  can  only  say  that  the  method  is  con- 
stantly growing  in  favor  with  me  personally,  and  that  the  piore  I  practise 
it  the  more  confidence  I  gain  in  it.     With  solutions  of  the  proper  strength 


HAEMORRHOIDS.  105 

the  danger  of  causing  sloughing  of  the  tumors  is  very  slight;  and  I  am 
not  at  all  sure  in  my  own  mind  that  once  more  surgery  is  not  indebted 
to  the  quacks  for  a  valuable  discovery  which  may  do  much  to  modify  the 
at  present  accepted  plans  of  treatment  of  this  disease. 

There  are  no  objections  to  this  method  which  do  not  apply  equally  to 
others.  I  have  once  seen  considerable  ulceration  result  from  it  in  the 
hands  of  another,  but  I  have  seen  an  equal  amount  follow  the  application 
of  the  ligature;  and  I  do  not  consider  this  as  a  danger  greatly  to  be  feared 
when  injections  of  proper  strength  are  introduced  in  the  proper  way.  It 
is  applicable  to  all  cases;  is  especially  adapted  to  bad  cases;  and  may  be 
nsed,  as  in  the  second  case,  where  a  cutting  operation  is  inadmissible.  It 
acts  by  setting  up  an  amount  of  irritation  within  the  tumor  which  results 
in  an  increase  of  connective  tissue,  a  closure  of  the  vascular  loops,  and 
a  consequent  hardening  and  decrease  in  the  size  of  the  haemorrhoid. 
Except  when  sloughing  occurs,  the  tumors  are  not,  therefore,  removed, 
but  are  rendered  inert  so  that  they  no  longer  either  bleed  or  come  down 
outside  of  the  body.  In  cases  in  which  the  sphincter  has  become  weak- 
ened by  distention,  the  injections  will  also  have  a  decided  efifect  in  con- 
tracting the  anal  orifice  as  do  injections  of  ergot  or  strychnine  in  cases 
of  prolapse. 

I  have  used  this  method  of  treatment  now  many  times  and,  except  in 
the  third  case  reported  here,  have  never  had  reason  to  regret  using  it,  or 
to  be  dissatisfied  with  its  results  as  far  as  I  have  been  able  to  follow  them. 
Although  I  should  be  very  slow  to  advocate  any  one  treatment  of  this 
affection  to  the  exclusion  of  all  others,  I  now  often  adopt  this  where 
Allingham's  operation  is  declined  by  the  patient,  and  as  yet  I  have  not 
known  it  to  fail.  Its  advantages  over  all  other  methods,  provided  its  re- 
sults prove  equally  satisfactory,  are  manifest  to  all.  The  patient  is  not 
terrified  at  the  outset  by  the  prospect  of  a  surgical  operation,  is  not  con- 
fined to  his  bed,  and  is  not  subjected  to  any  suffering.  The  cure  goes  on 
painlessly  and  almost  without  his  consciousness. 

The  method  requires  some  practice  and  some  skill  in  manipulation  in 
getting  a  good  view  of  the  point  to  be  injected  and  in  making  the  injec- 
tion properly.  In  the  first  three  cases  reported,  the  solution  employed 
was  one  part  of  pure  carbolic  acid  to  three  of  glycerin  and  three  of  water; 
in  the  last,  the  carbolic  acid  was  decreased  one-half  and  this  is  a  better 
solution  to  use.  The  amount  injected  each  time  was  about  five  drops. 
The  instrument  used  was  an  ordinary  •hypodermic  syringe  with  a  good 
sized  needle  through  which  the  solution  would  readily  pass.  When  the 
tumor  to  be  injected  is  prolapsed,  the  needle  may  be  thrust  into  it  without 
difficulty,  and  after  the  injection  is  made  the  tumor  should  be  gently  re- 
placed. If  it  be  allowed  to  stay  out  of  the  anus  for  a  few  moments  it  will 
be  seen  to  swell  up  and  become  black  and  hard  with  venous  blood.  There 
is  seldom  any  haemorrhage  from  the  operation,  but  occasionally  a  few 
drops  of  blood  will  follow  the  puncture.     If  the  tumor  is  not  protruded 


106  DISEASES   OF   THE    KECTUM    AND    ANUS. 

at  the  time  of  operation  it  may  be  seized  with  toothed  forceps  and  drawn 
out  and  held  while  the  injection  is  made.  The  injection  should  be 
landed  as  nearly  aS  possible  in  the  centre  of  the  hasmorrhoid,  the  needle 
being  entered  perpendicularly  from  the  apex,  and  not  passed  upward 
under  the  mucous  membrane  in  a  longitudinal  direction.  If  the  acid  be 
placed  simply  under  the  mucous  membrane  the  latter  will  die  and  an  ulcer 
result,  but  if  placed  more  deeply  the  danger  of  an  ulcer  is  much  decreased. 
Used  in  this  way  and  in  the  strength  last  indicated  the  acid  will  not  be 
followed  by  any  great  amount  of  pain.  Each  injection  should  be  followed 
by  a  day's  rest  in  the  horizontal  position.  No  change  need  be  made  in 
the  ordinary  diet  of  the  patient  provided  the  bowels  act  regularly  every 
day.  Only  one  tumor  should  be  injected  at  a  time  and  I  seldom  repeat 
the  injections  oftener  than  once  a  week.  It  will  sometimes  be  found 
necessary  to  inject  the  same  tumor  twice  or  three  times  when  it  is  a  large 
one. 

It  will  be  observed  that  in  the  cases  reported  the  length  of  time  dur- 
ing which  the  patient  was  under  treatment  was  in  each  case  except  the 
second  about  three  months.  I  have  no  doubt  that  this  could  be  much 
shortened,  were  it  necessary;  but  where  the  patient  is  at  no  time  confined 
to  the  house,  time  is  of  little  consequence,  and  I  seldom  repeat  the  appli- 
cations oftener  than  once  a  week,  preferring  to  see  the  full  effect  of  each 
one  before  giving  a  second.  Still,  were  there  any  reason  for  haste,  I 
should  not  hesitate  to  shorten  this  interval,  and  I  am  led  to  believe  that 
in  the  hands  of  the  quacks  the  time  is  considerably  shortened.  I  believe 
also  that  with  them  it  is  the  custom  to  produce  a  sloughing  of  each  tumor 
by  the  strength  of  the  injection,  and  once  or  twice  I  have  had  patients 
come  to  me  in  this  condition.  But  no  such  use  of  the  acid  is  necessary 
to  effect  a  cure,  and  this  result  is  one  which  I  try  very  carefully  to 
avoid. 

Treatment  by  Ligature. — This  is  the  method  of  treatment  which  has 
been  brought  to  such  perfection  by  Allingham,  and  which  usually  passes 
by  his  name.  It  consists  in  partially  cutting  through  the  haemorrhoid 
at  its  base,  and  tying  the  remainder.  It  is  performed  in  the  following 
manner. 

As  in  all  operations  on  the  rectum,  the  bowel  should  be  thoroughly 
cleared  by  a  cathartic  on  the  previous  day  and  by  an  enema  just  before 
operating.  The  patient  may  be  placed  either  on  the  side  or  in  the  lith- 
otomy position;  personally  I  prefer  the  latter.  The  sphincter  should  be 
carefully  dilated,  as  already  described,  and  this  is  a  step  of  great  practi- 
cal importance,  as  the  securing  of  complete  paralysis  of  the  muscle  will 
do  more  than  anything  else  to  prevent  pain  and  spasm  after  the  operation. 
In  cases  where  the  tumors  were  large  and  prolapsed  readily,  I  have  seen 
this  step  in  the  operation  omitted  as  unnecessary  by  good  surgeons;  and 
I  have  seen  a  week  of  great  suffering  to  the  patient  follow  the  omission. 
So  important  is  this  step  in  the  operation  for  the  relief  of  pain,  that  in 


H.CMORRHOIDS.  107 

some  cases  in  which  the  tumors,  were  so  extensive  and  the  sphincter  so 
dilated  that  they  could  easily  be  removed  without  it,  I  have  first  cut  off 
the  haemorrhoids  and  then  stretched  the  sphincter.  It  is  rather  a  rever- 
sal of  the  regular  order,  but  it  illustrates  the  fact  that  stretching  the  mus- 
cle should  not  be  omitted.  If  the  muscle  is  forcibly  and  suddenly  torn 
apart  by  the  operator,  a  fissure  may  result,  and  may  require  a  subsequent 
operation  for  its  cure  after  recovery  from  the  original  operation.  The 
tumors  being  thus  brought  into  full  view  by  the  introduction  of  a  specu- 
lum, one  is  seized  and  drawn  down  with  a  toothed  forceps.  The  selec- 
tion of  a  good  forceps  for  this  purpose  is  a  matter  of  considerable  import- 
ance. In  my  own  operations,  I  use  those  figured  below.  The  hold  is 
firm  and  the  handle  sufficiently  long  for  the  hand  of  the  assistant  to  bo 
out  of  the  way  of  the  operator  in  the  subsequent  steps. 


Fio.  Xi. 

Having  secured  a  good  firm  hold  on  the  tumor,  the  surgeon  transfers 
the  forceps  to  the  left  hand,  and  with  a  strong  and  long  pair  of  straight 
scissors  cuts  the  haemorrhoid  away  from  its  attachments  for  a  certain  dis- 
tance, beginning  from  below  and  cutting  upwards.  In  this  way  the  mass 
is  entirely  cut  off  except  at  its  upper  end,  where  the  artery  or  arteries 
which  feed  it  enter  it  from  above.  It  is  to  prevent  haemorrhage  from 
these  vessels  that  the  ligature  is  applied  instead  of  completely  cutting  off 
the  mass;  and  this  is  done  by  the  operator  after  transferring  the  forceps 
to  the  assistant. 

The  ligature  should  bo  of  stout  hemp,  something  stouter  than  ordi- 
nary ligature  silk  being  necessary.  The  string  should  be  tied  very 
tightly,  and  after  it  is  secured,  the  pile  may  be  cut  off  to  remove  as  much 
as  possible  of  tlic  dead  tissue  from  the  rectum.  Each  hemorrhoid  is 
thus  treated  in  succession,  and  after  all  are  removed,  a  suppository  of 
opium  is  introduced,  and  a  T-bandago  tightly  applied  over  a  compress  of 
lint  and  a  napkin.  Tlie  suppositories,  which  may  bo  repeated  each  niglit 
for  two  or  three  days,  will  servo  to  keep  the  bowels  confined;  and  when 
the  patient  begins  to  experience  a  desiro  to  go  to  stool,  a  laxative  may  be 
administered.  There  may  or  may  not  be  some  pain  when  the  bowels  first 
move,  and  this  will  depend  very  much  upon  the  thoroughness  with  which 
the  alimentary  canal  has  been  emptied  before  the  operation.  I  have  seen 
as  a  result  of  neglecting  this  previous  cathartic  a  female  patient  have  to 
rid  herself  of  a  hardened  mass  of  fsecos  of  the  size  of  an  egg  at  the  first 
motion  of  the  bowels  after  the  operation,  and  the  suffering  was  simply 


108  DISEASES    OF    THE    KECTUM!    AND    ANUS. 

atrocious.  If  there  be  a  little  blood  with  the  first  passage,  it  is  a  matter 
of  no  importance. 

The  ligatures  will  generally  come  away  about  the  end  of  the  first 
week,  and  the  patient  should  be  kept  in  bed  or  on  the  lounge  for  a  week 
longer.  This  in  an  active  person  will  sometimes  be  difficult  to  manage; 
but  no  other  course  should  be  sanctioned  by  the  surgeon,  for  the  reason 
that  when  the  ligature  comes  away,  an  ulcerated  spot  is  left:  and  under 
certain  circumstances,  the  most  effective  of  which  is  active  exercise,  these 
little  wounds  may  grow  larger  instead  of  smaller.  In  this  way  a  case  of 
internal  haemorrhoids  may  be  turned  by  an  operation  into  one  of  ulcera- 
tion of  the  rectum,  and  the  change  is  not  to  the  advantage  of  the  patient. 
One  such  case  I  have  had  in  my  own  practice  in  a  debilitated  patient  in 
poor  general  health;  and  a  long  course  of  careful  treatment  Avas  necessary 
to  effect  an  ultimate  cure. 

Nothing  has  been  said  regarding  primary  or  secondary  haemorrhage, 
for  the  reason  that  it  is  not  a  complication  to  be  looked  for.  When  re- 
tention of  urine  occurs,  as  it  often  will,  it  must  be  met  in  the  usual  way. 
The  diet  for  the  first  few  days  should  be  chiefly  fluid. 

This  operation,  thanks  to  Mr.  Allingkam,  is  now  so  well  and  so  favor- 
ably known,  that  but  little  need  be  said  in  addition.  It  is  as  safe  as  any 
operation  in  surgery,  and  by  it  the  surgeon  may  promise  his  patient  an 
absolute  and  permanent  cure  of  his  troubles  in  every  case.  This  is  saying  a 
great  deal,  but  not  too  much.  It  has  been  followed  by  fatal  results — but 
so  has  every  other  minor  surgical  operation;  and  the  chance  of  such  a  ter- 
mination is  so  slight  that  it  need  not  enter  into  the  calculation  of  the 
operator.  Of  all  the  operations  for  the  cure  of  internal  haemorrhoids  it 
will  be  found  the  most  satisfactory,  the  least  liable  to  complications  in  its 
performance,  and  to  unfortunate  after-consequences.  Once  in  my  own 
practice  after  applying  it  to  an  old  case  of  haemorrhoids  with  slight  pro- 
lapse and  almost  completely  surrounding  the  whole  circumference  of  the 
anus  with  ligatures,  I  have  been  obliged  to  subsequently  use  a  bougie  to 
prevent  a  threatened  contraction ;  but  this  I  rather  expected  to  be  obliged 
to  do  at  the  time,  and  injurious  contraction  need  not  be  feared  in  any 
ordinary  case.  I  can  confirm  Mr.  Allingham's  statement  that  the  opera- 
tion, when  performed  with  a  proper  regard  to  minor  details,  is  not  fol- 
lowed by  any  considerable  amount  of  suffering.  I  have  had  patients 
assure  me  that  the  first  day  following  its  performance  was  one  of  perfect 
comfort — in  fact  of  greater  ease  than  any  they  had  experienced  for  weeks 
previous. 

Operation  with  the  clamp  and  cautery. — This  is  generally  known  as 
Smith's  operation,  because  he  has  advocated  it  so  forcibly  and  practised  it 
with  such  good  results.  He  claims  no  credit  for  introducing  it,  however, 
this  being  due  to  Mr.  Cusack,  of  Dublin,  and  his  own  originality  has  been 
chiefly  spent  in  improving  the  clamp  which  is  shown  below. 

The  operation  consists  in  drawing  down  the  tumor,  embracing  its 


U^MOKRUUIDS.  109 

"base  in  the  clamp,  removing  it  with  sharp  scissors,  and  lastly  applying 
the  actual  cautery  freely  to  the  cut  surface.  It  is  important  to  isolate  the 
tumors  well  so  as  to  compress  them  easily  and  comi)letely.  and  in  some 
cases  where  the  haemorrhoid  runs,  as  it  were,  abruptly  into  thehypertro- 
phied  skin,  Smith  recommends  the  previous  making  of  a  slight  groove 
with  the  scissors  so  that  the  compression  of  the  neck  of  tumor  may  bo 
the  more  effectual.  The  base  should  not  be  divided  too  close  to  the  clump 
lest  there  be  not  enough  tissue  left  for  the  proper  application  of  the  hot 
iron.  The  latter  is  to  be  applied  very  thoroughly  and  slowly  at  a  black 
heat;  and  the  blades  of  the  clamp  may  then  be  gradually  released  by  the 
screw.  Should  any  vessel  not  thoroughly  cauterized  bleed  when  the 
pressure  is  taken  off,  the  clamp  must  be  again  screwed  up  and  the  cautery 
again  applied.     It  may  be  necessary  to  do  this  several  times. 

This  operation  is  claimed  by  Smith  to  be  almost  painless,  provided  the 


Fio.  36. 

cautery  does  not  touch  the  skin  and  the  clamp  is  fitted  with  the  proper 
ivory  protectors  against  the  transmission  of  heat.  Next  to  the  operation 
by  the  ligature,  it  is  the  best  of  all  the  surgical  procedures,  but  it  is  much 
better  adapted  to  old  cases  of  large  prolapsing  tumors  than  to  those  Avhich 
are  less  developed,  for  the  reason  that  there  is  more  for  the  clamp  to  take 
hold  of,  and  more  left  to  cut  off  after  the  clamp  is  in  position.  I  can 
hardly  imagine  how  the  o])cration  can  be  painless,  especially  when  a  pre- 
vious cutting  IS  done  with  the  scissors,  but  I  have  not  had  a  large  experi- 
ence with  it,  and  none  at  all  without  ether. 

With  the  means  already  enumerated  every  case  of  internal  haemor- 
rhoids may  be  cured  where  a  cure  is  desirable,  or  relieved  when  radical 
cure  is  out  of  the  question,  and  I  shall  not,  therefore,  take  the  space 
necessary  to  describe  the  various  others  which  either  have  been  or  are  at 
present  in  favor;  such  as  simple  dilatation  of  the  sphincters,  the  gal- 
vano-cautery  wire,  plunging  the  actual  cautery  into  tlio  substance  of  the 
haemorrhoid,  and  cauterizing  the  skin  of  the  anus  in  radiating  lines  to 
cause  contraction. 


110  DISEASES    OF    THE    KECTUM    AND    ANUS. 


OHAPTEE  YIE. 

PROLAPSE. 

Four  Varieties. — First  Variety:  Prolapse  of  the  Mucous  Membrane  Alone. — Second 
Variety:  Prolapse  of  all  the  Coats  of  the  Rectum. — Third  Variety:  Prolapse 
of  the  Upper  Part  of  the  Rectum  into  the  Lower,  or  Invagination. — Fourth 
Variety:  Invagination  in  the  Continuity  of  the  Bowel. — Prolapse  of  the  Mu- 
cous Membrane  alone. — Causes. — Symptoms. — Treatment:  Palliative  and 
Curative. — Prolapse  with  Haemorrhoids. — Treatment  by  Injections. — Cauteri- 
zation.— Description  of  Operation. — Smith's  Clamp. — Dupuytren's  Opera- 
tion.— Prolapse  of  the  Second  Degree. — Pathological  Changes. — Presence  of 
Peritoneum. — Strangulation. — Dangers  in  Forcible  Reduction. — Fatal  Case  of 
Reduction.— Advisability  of  Reducing  Inflamed  or  Gangrenous  Prolapse. — 
Excision  of  Prolapse  after  the  Formation  of  a  Slough. — Dangers  of  Operation 
of  Excision  in  Extensive  Prolapse. — Operation  by  Elastic  Ligature. — Third 
and  Fourth  Varieties. — Differences  between  Third  and  Fourth. — Degrees  of 
Invagination. — Anatomical  Appearances. — Pathology.^Relative  Frequency. 
— Symptoms. — Physical  Signs. — Acute  and  Chronic  Forms. — Diagnosis. — 
Differential  Diagnosis  from  Volvulus;  from  Stricture;  from  Internal  Hernia; 
from  Obstruction  by  Pressure  from  without  the  Bowel;  from  Foreign 
Bodies;  from  Peritonitis  with  Perforation. — Treatment. — Replacement  by 
Manipulation;  by  Injections. — Treatment  by  Puncture. — Laparotomy. — De- 
scription of  Operation. 

Of  prolapse  of  the  rectum  and  invagination  there  are  four  distinct 
varieties. 

1.  ProlaiJse  of  the  mucous  membrane  alooie. — Tliis,  which  is  sometimes 
spoken  of  as  "partial"  prolapse  because  only  a  part  of  the  wall  of  the 
rectum  is  involved  in  the  descent,  is  well  represented  in  Fig.  37. 

2.  Prolapse  of  all  the  coats  of  the  rectum  including,  when  the  disease 
IS  of  sufficient  extent,  the  peritoneum.     Fig.  38. 

3.  Prolapse  of  the  upper  part  of  the  rectum  into  the  lower  or  invagi- 
nation.    Fig.  39. 

4.  Invagination  m  the  Continuiti/  of  the  Intestine. — The  same  condi- 
tion as  the  thu'd  variety,  only  occurring  in  a  part  of  the  bowel  furiher 
away  from  the  rectum. 

The  first  form  is  a  mere  everting  of  the  mucous  membrane  of  the 
lowest  portion  of  the  rectum,  rendered  possible  by  the  laxity  of  the  sub- 
mucous connective  tissue.     It  is  seen  as  an  accompaniment  of  old  cases 


PROLAPSK. 


Ill 


of  hfemorrlioid:?,  jiiul  its  mechanism  may  be  studied  at  any  time  upon 
the  horse  in  wliich  it  occurs  naturally  at  the  close  of  each  act  of  defeca- 
tion. 

The  second  variety  is  an  exaggeration  of  the  fii'st,  in  which,  after  the 
submucous  connective  tissue  has  yielded  to  its  utmost,  the  whole  thick- 
ness of  the  rectum  begins  to  descend,  and  finally  protrudes.  It  follows, 
of  necessity,  that  after  this  protrusion  has  reached  a  certain  length,  the 


Fia.  "17.— First  Variety  of  Prolapse  (Mollitire), 


Fio.  38.— Second  Variety  of  Prolapse  (MolliOre). 


peritoneal  coat  must  also  descend  outside  of  the  body,  and  this  condition 
is  shown  at  a  glance  by  reference  to  the  plate. 

In  both  of  these  forms,  the  protrusion  begins  first  at  the  part  of  the 
rectum  nearest  the  anus.  In  tlie  third  form,  the  part  of  the  rectum 
higher  up  is  passed  through  that  nearer  the  anus,  and  what  is  known  as 
an  invagination  occurs.  This  condition  must,  of  necessity,  cause  a 
sulcus  or  groove  to  exi^t  between  the  containing  and  the  contained  portion; 


112  DISEASES    OF   THE    RECTUM    AND    ANUS. 

and  at  the  bottom  of  this  sulcus,  the  mucous  membrane  of  one  is 
directly  continuous  with  that  of  the  other.  The  deptli  of  this  sulcus 
must  depend  upon  the  point  at  which  the  invagination  occurs;  but  in  the 
variety  under  consideration,  its  bottom  can  generally  be  felt  by  intro- 
ducing the  finger  by  the  side  of  the  protruding  portion. 

In  the  fourth  variety,  this  sulcus  also  exists,  but  its  bottom  cannot  be 
felt,  the  point  at  which  the  invagination  has  occurred  being  in  the  con- 
tinuity of  the  bowel,  too  far  away  from  the  anus.  In  the  first  three 
forms  of  the  disease,  there  is  always  a  protrusion  of  a  portion  of  the 
bowel  through  the  anus;  in  the  fourth,  there  may  be  no  such  protrusion, 
the  lower  end  of  the  invaginated  bowel  being  still  within  the  rectum,  or, 
perhaps,  too  far  up  the  canal  to  be  seen  or  felt. 

Having  thus  briefly  defined  the  different  varieties  of  prolapse  and  in- 
vagination, we  shall  consider  each  one  in  detail. 

Prolajne  of  the  Mucous  Membrane  Alone. — This  is,  perhaps;  the  most 
common  of  all  the  varieties  of  the  disease  Avhen  we  take  into  considera- 
tion its  frequent  coexistence  with  haemorrhoids.     It  is  found  in  children 


Fig.  39.— Third  Form  of  Prolapse  (Bryant). 

most  often  between  the  years  of  two  and  four,  and  in  adults  it  is  more 
frequent  in  women  than  in  men.  Its  causes  are  various.  Among  them 
may  be  enumerated  the  following;  a.  Those  which  tend  mechanically 
to  draw  down  the  mucous  membrane,  such  as  haemorrhoids,  polypus, 
vegetations,  and  tumors,  h.  Those  which  tend  to  weaken  or  to  destroy 
the  action  of  the  sphincters,  such  as  ulcerations  or  incisions,  c.  Those 
Avhich  cause  muscular  spasm,  such  as  fissures,  worms,  dysentery,  phy- 
mosis,  cystitis,  calculus,  stricture  of  the  urethra,  and  enlarged  prosfate. 
d.  Those  which  produce  permanent  dilatation  and  weakening  of  the 
sphincters,  such  as  spinal  paralysis,  traumatism,  chronic  constipation, 
and  sodomy.  In  this  last  connection,  Molli^re'  details  a  very  interesting 
case  from  his  personal  observation  in  a  woman  suffering  from  vesico- 
vaginal fistula.  Her  husband,  a  brutish  peasant,  not  daring  to  practise 
coitus  in  the  ulcerated  vagina  of  his  wife,  subjected  her  to  unnatural 
intercourse  daily  for  more  than  a  year,  with  the  result  of  producing  a 
relaxation  of  the  sphincter  which  showed  itself  by  prolapse  to  an 
enormous  extent,  and  by  incontinence.     To  this  lack  of  tonicity  of  the 

1  Op.  cit.,  p.  202. 


PROLAPSE.  113 

sphincters  may  be  attributed  the  frequent  occurrence  of  prolapse  in 
feeble  and  badly  nourished  children,  e.  Those  which  produce  cedema 
and  swelling  of  the  pelvic  tissues,  such  as  pregnancy,  parturition,  fsecal 
accumulations,  and  hepatic  lesions.  In  this  connection  also,  Molli^re' 
details  an  instructive  experiment  which  may  easily  be  repeated  on  the 
cadaver.  He  says:  **  On  the  cadaver  of  a  young  girl,  I  introduced 
under  the  mucous  membrane  of  the  anus  a  blow-pipe,  and  fastened  it 
with  a  ligature.  By  practismg  insufflation,  the  air  instantly  spread  in 
the  sub-mucous  rectal  tissue,  and  the  mucous  membrane  escaped  from 
the  anus.  I  repeated  the  same  manoeuvre  at  another  point  of  the 
( ircumference  of  the  anus,  with  the  same  result.  By  dissection,  I  was 
able  to  assure  myself  that  only  the  mucous  membrane  had  been  raised 
up.  It  was  then  sufficient  in  this  case  to  cause  tumefaction  of  the  sub- 
mucous tissue,  to  produce  prolapse;  and,  moreover,  in  this  subject,  the 
anus  was  still  firmly  closed. "  /.  To  these  causes,  it  may  be  proper  to  add 
one  anatomical  one — the  undeveloped  sacrum  in  children,  which,  by  its 
straightness,  leaves  the  rectum  comparatively  unsupported. 

Symptoms. — This  first  form  of  prolapse  always  comes  on  gradually 
and  never  suddenly.  It  may  be  partial  or  complete  as  regards  the  cir- 
cumference of  the  anus,  being  in  some  cases  of  haemorrhoids  confined  to 
one  side  of  the  aperture,  and  in  others  involving  the  whole  circumference 
It  presents  itself  as  a  scarlet  or  livid  mass  (depending  upon  the  state  of 
contraction  of  the  sphincter)  projecting  from  the  anus;  covered  with  the 
natural  secretion  of  the  bowel;  directly  continuous  with  the  skin  on  one 
side  and  with  the  mucous  membrane  on  the  other;  and  arranged  in  folds 
which  radiate  from  the  central  aperture  toward  the  circumference.  It  is 
at  first  spontaneously  reducible,  or  at  least  easily  replaced  by  a  slight 
pressure,  and  remains  reduced  till  the  next  act  of  defecation;  but  as  the 
amount  of  prolapsed  membrane  increases,  the  difficulty  in  reduction  be- 
comes greater.  At  first  also  there  is  no  pain,  but  after  a  time  the  act  of 
defecation  comes  to  be  greatly  dreaded  by  the  patient,  and  the  suffering 
continues  till  the  tissue  is  replaced. 

Treatment. — The  first  step  in  the  treatment  of  prolapse  of  the  rectum 
to  which  the  surgeon  will  be  called  to  attend  will  generally  be  to  effect 
the  reduction  of  the  mass;  after  this  has  been  accomplished,  the  treat- 
ment may  be  either  palliative  or  curative.  In  children  a  prolapse  may 
generally  be  reduced  by  laying  the  patient  across  the  lap  on  its  face  and 
making  gentle  pressure  on  the  protruded  bowel  with  the  fingers  which 
have  been  well  oiled;  or  with  a  soft  greased  rag.  If  this  cannot  be  ac- 
complished by  a  gentle  taxis,  and  without  bruising  the  parts,  the  child 
should  at  once  be  etherized  and  a  curative  procedure  adopted.  It  is 
scarcely  worth  while  in  a  child  to  stop  to  try  the  various  methods  of  re- 


'  Op.  cit.,  p.  199. 


114:  DISEASES    OF   THE    RECTUM    AND    ANTJ8. 

duction  which  have  been  recommended  where  the  taxis  has  failed,  before 
resorting  to  this  step. 

In  an  adult,  however,  ether  and  operative  interference  may  both  be 
declined,  and  the  surgeon  may  have  to  tax  his  brain  to  accomplish  the 
reduction  without  the  aid  of  an  anaesthetic.  In  such  a  case,  after  gentle 
taxis  has  been  tried  with  the  patient  in  the  knee-elbow  position,  and 
failed,  cold  should  be  applied  while  the  patient  remains  on  the  face  in 
bed  with  a  pillow  under  the  pelvis;  and  this  may  be  alternated  with  warm 
poultices  and  with  plentiful  applications  of  an  ointment  composed  of 
equal  parts  of  ext.  of  belladonna  and  ext.  of  opium.  By  these  means  the 
most  effectual  of  which  is  position,  reduction  may  almost  ahvays  be  ac- 
complished. When  by  the  action  of  the  sphincter  the  prolapse  has 
become  gorged  with  blood  and  cedematous,  the  surgeon  is  often  tempted 
to  resort  to  leeches.  They  will  generally  give  relief  and  may  greatly 
facilitate  reduction,  but  they  are  not  free  from  the  danger  of  a  concealed 
haemorrhage  within  the  rectum  after  the  prolapse  has  been  replaced. 

The  palliative  treatment  is  directed  entirely  toward  diminishing 
the  frequency  and  the  amount  of  the  prolapse,  and  in  children  a  cure 
may  sometimes  be  obtained  by  these  means  without  resorting  to  surgical 
interference.  The  act  of  defecation  is  first  to  be  regulated,  and  should 
be  performed  with  the  patient  in  the  recumbent  posture  in  bed,  or  while 
standing.  One  buttock  may  also  be  drawn  aside  so  as  to  tighten  the 
anal  orifice  with  advantage;  and  any  source  of  irritation  which  produces 
frequent  defecation  and  straining  in  the  act  must  be  removed.  After 
the  action  of  the  bowels,  if  the  prolapse  has  occurred,  the  bowel  should  be 
thoroughly  washed  with  cold  water  and  a  solution  of  alum  (  3  i.  to  §  viii. ) 
before  it  is  returned.  Another  favorite  wash  is  composed  of  the  tincture 
of  iron,  xx.  to  xxx.  drops  to  four  ounces  of  water.  The  patient  should 
then  be  confined  to  the  bed  for  some  time  and  pressure  should  be  applied 
over  the  anus  by  a  pad  kept  in  place  by  a  T-bandage  in  the  adult,  or  by 
a  broad  strip  of  adhesive  plaster  in  children,  applied  so  as  to  draw  the 
buttocks  into  close  apposition.  A  rectal  supporter  may  also  be  worn 
when  the  patient  is  up  and  about,  and  perhaps  the  best  of  these  is  the 
one  made  by  Mathieu,  and  represented  in  the  figure. 

After  the  bowel  has  ceased  to  come  down  with  the  act  of  defecation, 
an  astringent  injection  may  be  given  every  night  with  advantage  and 
allowed  to  remain  in  all  night.  The  general  health  should  be  carefully 
attended  to;  tonics  should  be  administered  where  they  seem  to  be  indi- 
cated; and  if  well  borne,  cod-liver  oil  may  be  used  to  fulfil  the  double 
indication  of  tonic  and  laxative.  In  children  these  measures  may,  as  has 
been  said,  be  curative,  and,  in  fact,  the  disease  often  ceases  spontane- 
ously at  about  the  time  of  puberty;  but  in  adults  they  are  not  at  all 
likely  to  be  so,  and  more  radical  measures  will  generally  be  necessary. 
Of  these  there  are  several  which  are  effectual,  and  each  of  them  has  its 
supporters  and  advocates. 


PROLAPSE.  115 

In  cases  of  prolapse  attending  old  internal  haemorrhoids,  the  operation 
for  the  removal  of  the  latter  by  the  ligature  may  easily  be  extended  so  as 
to  cure  at  the  same  time  the  former  condition.  And  here  a  little  careful 
discrimination  may  be  necessary  to  distinguish  between  piles  and  pro- 
lapsed mucous  membrane.  The  piles  are  smooth,  hard,  and  shiny 
tumors;  the  prolapse  is  soft  and  velvety  to  the  feel,  and  generally 
surrounds  the  whole  margin  of  the  anus  without  being  divided  into  dis- 
tinct tumors.  In  such  a  case,  the  proper  course  to  pursue  is  to  divide 
the  prolapse  into  several  sections  with  the  scissors,  and  tie  off  each  one 
exactly  as  though  it  were  an  internal  haemorrhoid.  I  have  several  times 
performed  this  operation  with  the  happiest  results,  both  as  to  curing  the 
piles  and  the  prolapse;  but  caution  must  be  exercised  as  to  the  amount 
of  tissue  removed,  lest  too  great  a  degree  of  cicatricial  contraction  result. 

Since  beginnmg  the  use  of  injections  in  the  treatment  of  haemorrhoids, 
I  have  also  in  some  cases  effected  a  cure  of  this  form  of  prolapse  by  the 
use  of  carbolic  acid  in  the  same  way  as  for  piles.     The  idea  of  using  car- 


Fio.  40.— Rectal  Supporter. 

bolic  acid  for  this  purpose  is,  I  believe,  my  own,  and  came  naturally  from 
my  trials  of  the  remedy  in  haemorrhoids,  but  both  strychnine  and  ergot 
have  been  used  for  the  same  purpose  for  some  time. 

At  a  meeting  of  the  Therapeutical  Society,  December,  1879,  reported 
in  the  Gaz.  Hebdom.,  Jan.  2d,  1880,  Dr.  Ferrand  related  the  case  of  a 
lady  who  liad  suffered  three  years  from  prolapse,  the  tumor  being  nearly 
the  size  of  the  fist,  and  descending  even  when  she  walked  across  the 
room,  and  causing  great  suffering.  One  gmmme  and  twenty  centi- 
grammes of  a  solution,  composed  of  glycerin  and  water  fu'i  fifteen  parts, 
and  alkaline  hydrated  extract  of  ergot  two  parts,  was  injected  into  the 
ischio-rectal  fossa  beside  the  prolapse.  Considerable  benefit  resulted, 
and  three  other  injections  w^ere  practised  at  intervals  of  twenty  days,  ten 
days,  and  a  month,  with  the  result  of  effecting  a  cure.  The  patient  was 
seen  after  an  interval  of  six  months,  and  it  was  found  that  the  prolapse 
was  not  reproduced  even  by  such  exertion  as  going  up  several  flights  of 
stairs. 


116  DISEASES    OF   THE   KEOTUM   AND   AND8. 

Vidal '  also  has  recorded  three  successful  cases  of  cure  "with  ergotine.* 
The  first  was  that  of  a  mau,  aged  thirty-nine,  who  had  suffered  for  eight 
years.  After  five  injections  of  fifteen  drops  of  a  solution  of  ergotine,  at 
intervals  of  two  days,  the  mucous  membrane  scarcely  protruded  at  all. 
After  the  eleventh  injection  it  only  came  down  during  defecation  and 
returned  spontaneously.  The  whole  number  of  injections  was  twenty- 
two,  and  the  man  remained  perfectly  well  four  years  after.  The  second 
patient,  a  female,  aged  sixty-four,  was  cured  after  twenty-four  days' 
treatment,  and  remained  well  two  years  and  a  half  after.  The  third 
patient,  a  female,  aged  forty-five,  was  cured  in  fifteen  days  by  six  injec- 
tions of  twenty  or  twenty-five  drops  each.  The  solution  used  consisted 
of  fifteen  grains  of  Bonjean's  ergotine  dissolved  in  seventy-five  minims  of 
cherry-laurel  water.  The  injections  were  made  at  the  distance  of  one- 
fifth  of  an  inch  from  the  anus.  Acute  pain  always  followed,  and  con- 
traction of  the  sphincter  lasting  several  hours.  Several  times  an  injec- 
tion of  twenty-five  drops  of  the  solution  caused  spasm  of  the  neck  of  the 
bladder  and  retention  of  urine.  In  no  case  did  the  injections  produce 
any  local  inflammation  or  abscess.  Dr.  Vidal  has  more  recently  expressed 
himself '  as  preferring  Yvon's  solution  of  ergot  to  Bonjean's  ergotine,  as 
causing  less  pain. 

The  danger  to  be  avoided  in  this  method  of  treatment  is  the  use  of 
too  irritating  solutions,  or  solutions  in  too  great  quantity  which  shall 
excite  a  suppurative  action  and  produce  constitutional  poisonous  effects. 

Cauterization. — In  children  in  whom  milder  measures  have  failed,  a 
Tery  effectual  means  of  cure  is  the  application  of  fuming  nitric  acid  to 
the  mucous  membrane  of  the  prolapsed  part.  The  bowel  should  first  be 
carefully  wiped  off  with  a  towel  or  sponge,  and  the  acid  then  applied  by 
means  of  a  small  stick  all  over  the  mucous  membrane,  but  not  at  all  to 
the  skin  adjacent.  After  such  an  application  the  bowel  should  be 
replaced,  a  pad  of  lint  firmly  applied  over  the  anus  by  means  of  broad 
strips  of  adhesive  plaster,  and  the  bowels  confined  by  means  of  opium. 
Allingham  speaks  of  stuffing  the  rectum  with  wool  in  addition,  but  I 
have  always  found  the  pad  and  straps  sufficient  when  thoroughly  applied, 
and  the  child  kept  on  its  bed.  After  three  Or  four  days  the  straps  may 
be  removed,  and  the  bowels  moved  with  castor  oil.  In  a  large  proportion 
of  cases,  the  cure  will  be  found  complete,  though,  in  a  few  cases,  I  have 
seen  a  return  of  the  disease  after  a  few  months.'  In  any  case,  however, 
the  benefit  will  be  found  to  be  very  great,  and  should  the  disease  return, 
a  very  careful  search  should  be  instituted  for  some  existing  source  of 
irritation,  such  as  polypus,  phymosis,  or  calculus.  In  case  of  a  recur- 
rence, a  second  application  will  be  effectual  in  causing  a  cure. 

This  treatment,  though  successful  in  children,  is  by  no  means  so  in 


•  Paris  Medical,  August  28th,  1879. 
»Gaz.  Hebdom.,  Jan.  2d,  1880. 


PE0LAP8E.  117 

adults.  Allingham  calls  attention  to  the  occurrence  of  deep  sloughs  in 
old  persons  with  debilitated  constitutions ;  and,  as  a  result  of  such  a 
slough,  he  has  seen  an  almost  fatal  haemorrhage.  Stricture  of  the  rectum 
may,  without  doubt,  be  caused  by  too  free  use  of  this  remedy,  but  since 
it  follows  its  abuse  and  not  its  proper  use  in  appropriately  selected  cases, 
it  can  hardly  be  considered  an  objection. 

Linear  Cauterization. — In  adults  this  is  undoubtedly  the  best  means  at 
our  command  for  dealing  with  this  affection,  and  the  best  means  of  ap- 
plying it  is  that  recommended  by  Van  Buren,  with  Paquelin's  cautery. 

The  patient  is  at  first  etherized  and  placed  in  Sims's  position.  Van 
Buren  reduces  the  prolapse,  and  applies  the  iron  with  the  aid  of  a  spe- 
culum. Allingham  first  applies  the  iron  and  then  reduces  the  prolapse. 
In  either  case,  from  three  to  six  vertical  stripes  should  be  made  upon  the 
mucous  membrane,  with  the  iron  heated  to  a  dull-red  heat.  The  caute- 
rization should  begin  about  three  inches  up  the  rectum,  and  end  at  the 
junction  of  the  skin  and  mucous  membrane.  They  should  also  be 
deeper  at  the  end,  where  there  is  no  danger,  than  at  the  beginning,  where 
the  bowel  may  be  perforated.  Van  Buren  recommends  that  the  iron  be 
bent  at  a  right  angle  a  short  distance  from  the  end,  so  that  it  may  be  the 
more  thoroughly  applied  to  the  concavity  of  the  rectum,  and  that,  in 
mild  cases,  a  small  iron  should  be  used,  "no  thicker  than  an  ordinary 
j>robe."  Allingham,  in  bad  cases,  burns  through  the  sphincter  muscle 
at  two  opposite  points,  after  reducing  the  bowel,  and  inserts  a  small 
}>ledget  of  oiled  wool.  By  this  burning  through  the  sphincter,  the 
patulous  condition  of  the  anus  is  overcome.  The  result  of  the  operation 
is  to  decrease  the  circumference  of  the  anal  orifice,  and,  in  this  way,  to 
effect  a  cure.  The  patient  should  be  confined  absolutely  to  bed  till  the 
wounds  are  entirely  healed,  so  that  a  recurrence  of  the  descent  may  be 
effectually  avoided. 

For  some  time  after  the  healing,  and  after  the  patient  is  allowed  to  be 
up  and  about,  in  fact,  until  the  full  effect  of  the  operation  has  been  ob- 
tained, a  bed-pan  should  be  used.  The  first  ojieration,  if  thoroughly 
performed,  will  probably  result  in  permanent  cure.  Should  it  not,  it 
may  be  repeated.  The  only  danger  in  connection  with  it  is  the  occur- 
rence of  secondary  hjemorrhage  when  the  sloughs  separate,  and  of 
primary  haemorrhage  from  large  veins  at  the  time  of  the  application  of 
the  iron.  To  avoid  this,  Allingham  recommends  the  choosing  of  points 
for  cauterization  which  are  free  from  large  venous  pouches,  such  as  may 
be  visible  on  the  surface  of  the  tumor. 

In  old  cases  of  extensive  disease,  the  operation  as  thus  described  may 
not  be  effectual,  and  it  may  be  necessary  actually  to  produce  a  stricture 
at  the  anus  to  prevent  recurrence  of  the  trouble.  There  is,  perhaps,  no 
better  means  of  accomplishing  this  than  to  apply  the  iron  to  the  whole 
circumference  of  tlie  anus,  circularly,  instead  of  in  longitudinal  stripes; 
but  such  an  operation  will  seldom  be  called  for. 


118  DISEASES    OF   THE    RECTUM    AND    ANUS. 

There  is  one  other  method  of  dealing  with  this  affection,  which, 
though  not  as.  simple  as  the  cautery-iron  alone,  is  well  worthy  of  trial, 
and  that  is  Smith's  operation  with  the  clamp  and  cautery.  We  have 
already  given  a  figure  and  description  of  the  clamp  and  the  operation  in 
speaking  of  haemorrhoids,  but  the  operation  is  even  better  adapted  to 
cases  of  prolapse  than  to  hsemorrhoids,  the  mass  being  larger  and  more 
readily  seized,  cut  off,  and  cauterized. 

Having  thus  described  the  most  effectual  means  of  dealing  with  this 
troublesome  affection,  it  is  scarce  worth  while  to  describe  the  various 
cutting  operations  by  which  pieces  are  removed  either  from  the  mucous 
membrane  alone,  or  from  the  sphmcter  muscle,  with  the  object  of  ac- 
complishing the  same  result  that  is  more  readily  attained  with  the 
cautery  iron.  Dupuytren's  operation  consisted  in  removing  three  ellip- 
tical folds  of  skin  and  mucous  membrane  from  the  verge  of  the  anus.  The 
same  idea  has  been  more  recently  applied  in  Germany. '  Robert  and 
Dieffenbach  cut  out  wedge-shaped  pieces,  and  approximated  the  edges 
with  deep  sutures  ;  and  the  latter  even  went  so  far  as  to  cut  off  the  whole 
tumor — an  operation  now  seldom  practised,  except  in  slight  cases,  such 
as  those  accompanying  internal  haemorrhoids. 

Prolapse  of  the  Second  Degree. — As  already  said,  the  second  variety  of 
prolapse  differs  from  the  first  in  the  fact  that  it  is  composed  of  the  whole 
thickness  of  the  bowel,  and,  therefore,  when  of  sufficient  length,  of  peri^ 
toneum  also.  It  is  probable  that  every  prolapse  of  more  than  two  inches 
in  length  may  contain  peritoneum;  and  it  follows  from  the  anatomy  of 
the  parts  that  the  peritoneum  will  extend  lower  on  the  front  than  behind. 
In  the  peritoneal  pouch  thus  formed  in  front  there  may  be  located  coils 
of  intestine,  an  ovary,  or  a  part  of  the  bladder.  In  this  form  of  prolapse 
there  is  no  groove  or  sulcus,  as  is  shown  by  the  figure,  and  the  absence 
of  such  a  groove  is,  therefore,  no  proof  of  the  non-existence  of  a  fold  of 
peritoneum  in  the  tumor. 

It  is  a  mistake  to  suppose  that  this  second  variety  is  not  met  with  in 
children,  for  it  is  only  an  exaggerated  form  of  the  first,  being  the  next 
step  in  the  descent  after  the  submucous  connective  tissue  has  yielded  its 
utmost;  and  exaggerated  cases  of  prolapse  are  often  seen  in  children.  It 
is  distinguished  from  the  first  variety — first  of  all,  by  its  size.  The  first 
is  never  very  large;  while  the  second,  from  the  nature  of  the  case,  must 
be  of  considerable  dimensions.  Again,  a  prolapse  of  the  first  variety  is 
seldom  of  long  standing;  while  one  of  the  second  is  generally  so.  The 
second  generally  follows  the  first,  but  a  prolapse  may  be  of  this  variety 
from  the  beginning;  resulting,  in  such  a  case,  generally  from  violent 
straining,  and  coming  on  suddenly.  The  first  variety  is  not  firm  and 
thick  to  the  feel;  the  folds  of  mucous  membrane  radiate  from  the  orifice 

'  "  Eine  neue  Methode  der  ope  rati  ven  Behandlung  des  Mastdannvorfalls." 
Deutsche  Med.  Woch.,  No.  33,  1880. 


PBOLAP8E.  •  119 

to  the  circumference,  and  the  opening  is  circular  and  patulous.  In  the 
second,  the  orifice  is  slit-like  and  is  drawn  backwards  by  the  attachment 
of  the  meso-rectum,  or  in  females  forward  by  the  closer  attachment  to 
t!ie  vagina.  The  form  of  the  tumor  is  conical,  its  walls  are  thick  and 
fii-m,  and  when  pressed  between  the  fingers,  the  gurgling  of  gas  in  a  con- 
tained loop  of  intestine  may  sometimes  be  detected,  and  a  resonance  may 
be  obtained  on  percussion. 

If  such  a  tumor  be  carefully  dissected,  the  coats  of  the  protruded 
bowel  will  be  found  enlarged;  the  mucous  membrane  will  be  seen  to  be 
thickened  and  dense  in  structure,  especially  at  the  free  extremity;  and  it 
will  also  sometimes  be  found  eroded  and  granular.  The  submucous  are- 
olar tissue  will  be  seen  to  be  infiltrated  with  albuminous  deposit,  and  the 
muscular  layers  will  be  hypertrophied.  Owing  to  these  changes,  the 
bowel  is  actually  increased  in  size,  and  becomes  too  large  to  be  retained  in 
its  proper  place;  which  explains  the  difficulty  often  experienced  in  reduc- 
ing it  and  in  keeping  it  reduced,  in  spite  of  the  constant  straining  and 
desire  for  defecation  wiiich  it  produces.  These  changes  in  the  mucous 
membrane  may  in  rare  cases  result  in  the  production  of  a  foul,  hard, 
bleeding,  eroded  mass,  which  may  at  the  first  glance  strongly  suggest 
malignant  growth.  The  bleeding  from  a  prolapsed  rectum  is  commonly 
in  the  form  of  a  general  oozing,  and  applications  of  astringents  may  be 
necessary  for  its  control. 

Strangulation  is  rare  in  infants  and  in  feeble  old  people,  but  in  a 
3trong  person  the  sphincter  may  be  sufficiently  powerful  to  produce  such 
a  result.  A  strangulation  may  be  only  temporary  when  met  by  the 
jiroper  means,  or  it  may  continue  long  enough  to  cause  ulceration  and 
partial  gangrene;  the  latter,  however,  is  rare.  When  it  occurs,  it  is  pos- 
sible for  it  to  end  fatally  from  the  contiguity  of  the  peritoneum;  but  it 
more  often  results  in  a  spontaneous  cure  of  the  prolapse,  and  in  a  cica- 
tricial stricture,  the  location  of  which  will  depend  upon  the  length  of  the 
prolapsed  portion  and  the  point  at  which  the  sphacelus  occurs. 

The  causes  of  the  second  variety  are  the  same  as  of  the  first,  and  need 
not  again  be  enumerated.  The  symptoms  also  are  the  same,  with  the  ad- 
dition of  more  or  less  incontinence  of  faeces  in  old  cases;  but  the  treat- 
ment is  not  the  same  in  all  respects;  for  certain  measures  which  may  be 
safe  when  a  prolapse  contains  no  peritoneum  may  be  fatal  under  the  op- 
posite condition. 

In  cases  in  which  curative  measures  are  out  of  the  question,  the  haem- 
orrhages and  the  erosions  may  be  relieved  by  suitable  applications,  rest 
in  bed,  defecation  in  the  recumbent  posture,  etc.  Persulphate  of  iron  is 
j)erha})S  as  good  an  application  to  the  bleeding  surface  :is  any  other;  and 
weak  solutions  of  nitrate  of  silver  often  have  a  good  effect  upon  the  ero- 
sions. The  reduction  of  a  prolapse  of  the  second  degree  is  by  no  means 
as  simple  a  matter  as  that  of  the  first.  When  the  sphincter  is  tiglit  and 
the  tumor  cedematous,  it  may  be  nearly  impossible;  and  in   old  cases 


120  DISEASES    OF    THE    RECTUM    AND    ANUS. 

where  the  opposite  condition  of  the  sphincter  obtains,  it  may  be  equally 
difficult  to  keep  the  parts  within  the  body  after  placing  them  there. 
The  latter  may,  however,  generally  be  accomplished  by  the  means  already 
enumerated,  and  the  reduction  in  obstinate  cases  may  generally  be  ob- 
tained through  the  influence  of  anaesthesia.  The  dangers  which  may 
attend  an  attempt  at  reduction  by  taxis  are  well  illustrated  in  the  follow- 
ing case. 

Case  X. — Complete  prolapse  of  the  rectum;  rupture  of  the  howel 
during  reduction. '  The  case  was  that  of  a  woman,  aged  forty-six  years, 
who  about  twelve  years  before,  a  short  time  after  a  difficult  labor,  had 
begun  to  suffer  from  prolapse  which  came  down  daily  at  the  time  of  de- 
fecation, and  was  easily  reducible.  She  was  seen  by  the  doctor  at  a  time 
when  the  tumor  had  been  down  nearly  twenty-four  hours  and  had  resisted 
all  the  efforts  of  herself  and  female  friends  at  replacement.  She  had 
passed  a  restless  night  and  was  much  fatigued  by  her  journey  in  an  old 
cart,  but  had  experienced  no  bad  symptoms  referable  to  the  stomach  or 
bowels.  The  doctor  found  at  the  anus  a  tumor  larger  than  the  fist, 
round,  red,  and  covered  with  bloody  mucous. 

The  prolapse  was  directly  continuous  with  the  margin  of  the  anus  in 
such  a  manner  as  to  render  the  introduction  of  a  sound  between  them 
impossible.  At  the  extremity  of  the  tumor  there  was  a  rounded  aperture 
which  admitted  the  finger  without  obstacle.  To  accomplish  the  reduc- 
tion the  woman  was  placed  on  the  bed  with  the  thighs  separated;  the 
tumor  was  seized  in  the  palms  of  the  two  hands  and  the  ends  of  the  fin- 
gers, and  a  gentle  circular  compression  was  exercised  in  order  to  diminish 
its  volume  and  cause  it  to  go  up  by  an  operation  similar  to  the  taxis. 
The  resistance  being  great,  a  few  moments  were  allowed  for  rest,  and  after 
a  quarter  of  an  hour  the  same  manoeuvre  was  repeated  after  having  en- 
veloped the  tumor  in  a  cold  cloth.  "  After  a  few  moments  I  felt,"  says 
the  narrator,  "  during  a  violent 'effort  of  the  patient,  the  tumor  distend 
under  my  fingers,  and  at  the  same  time  I  heard  a  noise  similar  to  that 
made  by  tearing  parchment.  At  the  same  time  the  tumor  suddenly  dis- 
appeared of  itself,  and  syncope,  nausea,  and  a  marked  change  in  the  ex- 
pression of  the  face  supervened. 

When  the  patient  came  to  herself  she  complained  of  severe  colic.  I 
then  found  outside  of  the  anus  a  loop  of  intestine  which  I  easily  replaced, 
and  on  introducing  the  finger  into  the  rectum  I  recognized  at  a  consider- 
able height  an  irregular  longitudinal  rent  the  extent  of  which  I  was  un- 
able to  determine.  I  placed  a  tampon  of  lint  over  the  anus  and  kept  it 
in  place  with  a  T  bandage  and  compress.  I  sent  the  patient  to  her  home, 
ordering  that  nothing  be  disarranged.  As  the  case  was  very  serious,  I 
requested  a  neighboring  confrere  to  come  and  aid  me  with  his  advice. 
At  our  arrival,  six  hours  after  the  accident,  I  found  the  patient  sitting  by 

•  Condensed  from  report  by  Dr.  Roche,  Revue  Med.-Chirurg.,  1853. 


PROLAP6B.  121 

the  corner  of  the  fire,  without  the  dressings.  Between  the  separated 
thighs  were  exposed,  in  tlio  midst  of  the  ashes,  the  large  and  a  consider- 
able part  of  the  small  intestines,  distended  with  gas,  cold,  and  in  several 
spots  livid.  The  face  was  Hippocratic,  the  pulse  thready  and  much 
accelemted,  the  voice  feeble;  and  to  this  was  joined  colic  and  continual 
vomiting.  After  having  placed  the  woman  in  bed  and  raised  the  intes- 
tines, the  mass  was  replaced  within  the  body,  the  former  dressing  was 
applied,  and  the  woman  died  in  a  few  hours." 

Two  questions  may  arise  in  this  connection.  Should  reduction  be 
tried  when  the  tumor  is  inflamed;  and  should  it  be  tried  in  case  of  a 
circular  slough?  In  answering  the  first  question,  the  distinction  must  be 
made  between  a  prolapse  which  is  merely  strangulated  and  one  which  is 
inflamed.  The  appearances  may  be  much  the  same,  but  an  old  pro- 
lapse in  an  old  person  when  found  in  this  condition  is  much  more  apt  to 
be  inflamed  tlian  strangulated,  for  the  sphincter  muscle  in  such  cases 
has  generally  lost  the  power  of  forcible  constriction.  The  danger  in  re- 
turning an  inflamed  prolapse  into  the  body  is  that  the  inflammation 
may  extend  and  cause  general  and  fatal  peritonitis;  and  as  a  rule  it  is 
safer  not  to  employ  the  taxis  in  such  a  case,  but  to  put  the  patient  in  bed 
and  treat  it  by  local  applications  and  rest  till  the  acute  symptoms  have 
disappeared. 

In  answer  to  the  second  question,  Molli^re'  recommends  extirpation  of 
the  prolapsed  portion  rather  than  its  reduction  when  there  is  a  circular 
slough,  on  the  ground  that  no  matter  how  radical  such  a  step  may  appear  at 
first  sight,  it  is  better  than  leaving  the  case  to  nature.  For  a  circular 
slough  means  inevitably  a  cicatricial  stricture;  and  if  the  prolapse  be  ex- 
tensive, a  stricture  situated  high  up  in  the  rectum  or  sigmoid  fluxure  be- 
yond the  reach  of  art.  As  preferable  to  this  he  recommends  the  complete 
ablation  of  the  tumor  with  all  the  dangers  which  attend  such  a  step. 
These  dangers  are  easily  understood  to  be  haemorrhage,  hernia  of  the 
intestines  through  the  incision,  and  peritonitis.  Each  may  bo  avoided 
where  the  surgeon  is  prepared  beforehand  for  their  occurrence,  and 
Molliere  relates  one  case  where  the  operation  was  performed  by  himself 
with  the  hot  trow,  but  the  patient  **  died  on  the  eighth  day  from  the 
efi^ects  of  the  chloroform  "  so  that  he  was  unable  to  decide  on  the  value 
of  the  operation. 

Excision  with  the  surgeon's  eyes  open  to  the  fact  that  he  is  dealing 
with  peritoneum  may  perhaps  be  done  with  success  under  such  circum- 
stances. At  all  events  it  is  a  very  different  matter  from  excision  of  this 
variety  of  prolapse  under  the  impression  that  it  is  the  one  previously 
described,  and  contains  no  peritoneum,  as  the  following  cjise  will  show. 
Van  Buren'  says:     "  I  have  reliable  information  of  a  case  in  which  the 

'  Op.  cit.,  p.  240. 
»  Op.  cit.,  p.  60. 


122  DISEASES    OF    THE    RECTUM    AND    ANUS. 

removal  of  a  '  compete  prolapse '  of  long  standing,  in  a  child,  was  quite 
recently  undertaken  by  a  hospital  surgeon  of  mature  years.  The  protest 
of  a  junior  colleague  led  the  operator  to  pass  some  deep  sutures,  in 
deference  to  a  fear  expressed  as  to  the  probability  of  intestinal  protrusion, 
hut  he  was  confident  that  the  tumor  consisted  of  mucous  membrane 
alone,  and  proceeded  to  remove  it.  Notwithstanding  the  deep  sutures, 
protrusion  of  several  coils  of  small  intestine  did  occur,  and  tlie  child 
died,  in  collapse,  witliin  twenty-four  hours." 

In  this  form  of  the  disease,  the  surgeon  may  find  it  better  after 
mature  deliberation  not  to  attempt  a  radical  cure,  but  to  confine  his  efforts 
solely  to  palliation.  The  following  case  illustrates  the  danger  of  atteilipted 
removal  of  a  part  of  the  mass  in  an  old  and  extensive  prolapse. 

Case  XL — "The  patient  was  an  elderly  man  who  had  a  prolapsus  as 
big  as  a  cocoa-nut  always  coming  down,  and  rendering  his  life  a  burden. 
He  had  already  been  operated  upon  twice  by  a  hospital  surgeon,  but  in 
Tain.  The  patient  was  then  sent  to  me,  and,  formidable  as  the  case 
looked,  I  determined  to  undertake  it.  I  applied  the  clamp  deeply  in 
three  different  directions.  There  was  a  great  deal  of  bleeding  and  I  had 
to  apply  the  cautery  over  and  over  again  before  I  could  stop  it;  and  then, 
just  as  I  was  finishing  the  operation,  a  most  untoward  event  occurred — 
severe  vomiting,  as  the  result  of  the  anaesthetic,  took  place.  The  pro- 
lapsus was  forced  still  further  down;  and  before  I  and  my  assistants 
•could  return  the  parts,  the  violent  action  of  the  abdominal  muscles  was 
such  that  the  weakened  coat  of  the  bowel  gave  way,  and  a  knuckle  of  small 
intestine  actually  protruded  through  the  rent  thus  made.  I  carefully 
returned  this  as  soon  as  the  vomiting  ceased,  and  anxiously  waited  the 
result.  Our  house-surgeon,  Mr.  Newmarch,  watched  the  patient  with 
great  care  and  treated  him  with  great  skill,  keeping  him  constantly  under 
the  influence  of  opium,  and  locking  up  his  bowels  for  several  days.  The 
result  was  not  a  single  bad  symptom  of  any  kind.  On  the  first  action  of 
the  bowels  there  was  no  protrusion,  nor  afterwards;  and  as  soon  as  the 
man  was  fairly  recovered  I  removed  three  longitudinal  folds  of  skin  from 
the  anus,  so  as  further  to  tighten  the  parts.  The  man  was  completely 
■cured.  Now,  the  lesson  this  case  teaches  is  this — not  to  employ  an  agent 
which  could  cause  vomiting;  because,  of  course,  in  such  a  terribly  severe 
case  as  this  it  is  absolutely  necessary  to  clamp  deeply,  and  thus  weaken 
the  bowel.  It  was  a  most  unlooked-for  accident,  not  likely  to  occur 
again;  in  fact,  it  is  hardly  reasonable  to  expect  to  meet  with  another  such 
a  case  for  operation.  I  have,  however,  been  called  to  cases  as  bad  or 
worse,  but  where  no  operation  could  be  recommended."  ' 

Dr.  Klebei'g  has  utilized  the  elastic  ligature  in  operating  upon  severe 
cases  of  prolapse:  and,  it  may  be,  that  if  the  mass  has  to  be  removed  at 


»  Henrr  Smith,  Lancet,  Mar.  15th,  1880. 


PROLAPSE.      •  123 

all,  the  method  he  describes  is  the  preferable  one.  The  operation  is  per- 
formed as  follows. ' 

Case  XII. — Operation.  On  the  previous  day  a  dose  of  castor  oil  was 
given,  and  on  the  morning  before  the  operation  an  enema  of  luke-warm 
water  was  administered  high  up  the  bowel.  Immediately  before,  a  glass 
of  wine  and  one  grain  of  opium  were  given.  After  the  patient  had 
pressed  down  tiie  gut  as  far  as  he  could  ho  was  placed  on  the  operating 
table  in  the  lateral  position  with  the  pelvis  raised  and  shoulders  turned 
downward.  Chloroform  was  then  administered.  In  two  cases  Kleberg  has 
operated  without  chloroform  because  the  patients  were  in  such  a  miserable 
condition  that  he  was  afraid  to  narcotize  them  thoroughly,  and  an  incom- 
plete narcosis  has  all  the  dangers  of  profound  anaBsthesia  and  none  of  its 
advantages.  After  the  chloroform,  he  says,  "  I  carefully  examined  about 
tiie  rectum  at  the  junction  of  the  skin  and  mucous  membrane  in  order  to 
discover  the  sphincter  ani — a  procedure  that  was  more  difficult  than  one 
would  think,  because  it  had  become  so  stretched  and  atrophied  that  I 
could  only  make  it  out  by  feeling  under  the  fingers  the  coarser  fibres 
running  across  the  longitudinal  axis  of  the  bowel.  Of  anything  like  the 
normal  muscle  there  was  nothing  to  be  discovered. 

An  assistant,  at  this  point,  surrounded  with  all  the  fingers  the  pro- 
lapsus from  above,  the  points  of  the  fingers  being  directed  towards  the 
free  end  of  tlie  prolapsus,  and  pressed  as  hard  as  possible  into  the  gut  at 
a  point  perhaps  half  an  inch  below  the  supposed  sphincter.  Immediately 
in  front  of  the  ends  of  the  assistant's  fingers  I  then  placed  a  good,  fresh, 
unfenestrated  drainage  tube  of  rubber,  one  and  one  half  lines  in  diameter, 
around  the  prolapsus,  and  drew  it  only  as  tight  as  seemed  necessary  to 
atop  the  circulation.  The  elastic  ligature  was  brought  to  the  necessary 
tension  by  means  of  an  easily-untied  slip-knot  of  silk  thrown  under  it. 

The  assistant  now  had  both  hands  free  ;  and  from  this  time  on  the 
operation  was  performed  under  the  carbolic  spray.  A  few  lines  beneath 
the  ligature  I  now  made  a  longitudinal  incision  two  inches  long  through 
the  prolapsed  gut,  and  in  this  way  opened  the  sac  formed  by  the  drawing 
down  of  the  peritoneum.  Then  I  seized  the  elastic  ligature  with  the 
forceps  and  fixed  it  firmy.  It  was  thus  an  easy  matter  to  push  back  into 
the  peritoneal  cavity  a  protruding  loop  of  intestine  without  the  slightest 
bleeding  taking  place  into  the  wound  or  any  air  entering  the  peritoneal 
cavity  ;  because  the  elastic  pressure  follows  so  rapidly  all  the  movements 
that  no  opening  can  exist  anywhere. 

After  I  iiad  convinced  myself  that  the  peritoneal  sac  was  empty,  and 
that  no  invagination  of  the  intestine  was  present,  but,  on  the  other  hand, 
only  that  part  of  tlie  gut  which  was  to  be  removed  lay  in  front  of  the 
ligature,  I   thrust  the  largest  size  LueFs  pocket  trocar  through  the  pro- 

'  Ueber  die  Anwendung  der  elastischen  Ligatur  zur  Operation  sehr  schwerer 
FaUe  von  Prolapsus  Recti.     Arch.  fQr  Klin.  Chirurg.,  vol.  xxiv.,  p.  840. 


124  DISEASES    OF   THE   RECTUM   AND    ANUS. 

lapsus,  immediately  below  the  elastic  ligature,  from  before  backwards, 
and  passed  through  the  canula  two  elastic  drainage  tubes  of  one  and  one- 
half  lines  in  diameter,  and,  after  removing  the  canula,  tied  them  as 
tightly  as  possible,  one  on  the  right  side,  the  other  on  the  left.  These 
knots  were  secured  against  slipping  by  means  of  the  knot  of  silk.  The 
first  provision  against  haemorrhage — the  elastic  ligature  applied  after 
Esmarch's  plan — was  then  removed  and  the  prolapsus  cut  off  Avith  the  scis- 
sors one  inch  in  front  of  the  permanent  ligatures.  After  a  few  minutes* 
time,  during  which  I  kneaded  the  parts  which  still  remained  and  lay  above 
the  ligatures  thoroughly,  and  as  far  as  possible  removed  the  fluids  from 
them;  I  covered  the  parts  around  the  stump  with  cotton,  and  soaked  that 
part  of  the  jorolapse  which  still  remained  above  the  ligature  with  a  solution 
of  chloride  of  zinc,  dried  it,  squeezed  the  soft  parts  once  more,  thoroughly 
applied  the  chloride  of  zinc  again,  and  then  covered  the  whole  with  dry 
cotton-batting,  giving  the  patient  instructions  to  remove  this  as  soon  as 
it  became  moist  and  to  replace  it  with  dry,  and  to  give  the  air  all 
possible  access  to  the  parts." 

No  fever  followed  the  operation,  and  the  pain  was  bearable,  with  the 
aid  of  an  occasional  opiate.  On  the  next  day  the  parts  had  so  far  shrunk 
as  to  leave  a  concavity  at  the  anus  where  before  there  had  been  a  bulging. 
There  was  no  bleeding,  no  peritoneal  irritation,  and  only  slight  tenesmus. 
On  the  fourth  day  the  first  ligature  cut  out,  and  the  second  on  the  fifth. 
The  rectum  was  irrigated  twice  a  day  with  water  and  permanganate  of 
potash,  and  on  the  seventh  day  a  dose  of  castor  oil  was  followed  by  a  large 
evacuation  while  the  patient  was  on  his  back  without  pain  or  hsemorrhage. 
The  passage,  however,  was  involuntary.  On  the  fourteenth  day  the 
wound  was  healed,  the  general  condition  of  the  patient  excellent,  and  the 
evacuations  regular  but  still  involuntary.  The  sphincter  at  this  time 
began  to  be  appreciable,  and  there  was  no  protrusion  of  the  bowel,  the 
patient  going  about  and  wearing  a  bandage.  One  month  later  he  had 
control  of  solid  faeces,  but  there  was  still  a  slight  discharge  of  mucus  ;  and 
after  another  month  he  was  entirely  well. 

In  this  case  the  prolapse  was  about  a  foot  in  length  and  six  inches  in 
diameter.  The  mucous  membrane  was  spongy,  bleeding,  excoriated, 
and  ulcerated.  The  patient  had  been  sick  for  two  years,  had  been  bed- 
ridden for  two  months,  and  was  waxy  pale. 

Another  case  by  the  same' surgeon  and  the  same  method  ended  fatally, 
but  can  hardly  be  considered  a  fair  test  of  the  dangers  of  the  operation, 
on  account  of  the  exceedingly  bad  condition  of  tlie  patient. 

Tliird  and  fourth  varieties. — These  two  forms  of  invagination  will  be 
described  together  because  of  the  fact  that  they  differ  from  each  other 
not  at  all  in  their  nature  but  only  in  extent  and  location.  It  will  be  ob- 
served that  the  word  prolapse  is  now  dropped  and  invagination  substi- 
tuted which  more  aptly  expresses  the  condition.  The  essential  difference 
between  the  disease  now  to  be  considered  and  the  forms  already  described 


PROLAPSE.  125 

consists  in  the  fact  that  while  in  the  latter  the  bowel  begins  to  slip  down 
from  its  lowest  portion  at  the  anus,  in  the  former  the  lowest  portion  at 
the  anus  remains  in  its  proper  position  and  the  bowel  from  above  is  tele- 
scoped within  it.  Under  these  circumstances  it  isevident,as  is  shown  in 
Fig.  39,  that  the  affected  portion  of  the  bowel  must  consist  of  three  differ- 
ent and  distinct  cylinders,  an  outer  one  which  contains  the  other  two,  and 
two  included  portions,  one  of  which  is  the  entering  and  the  other  the  re- 
turning bowel. 

When  the  upper  part  of  the  rectum  becomes  invaginated  in  this  way 
within  the  lower,  the  included  portion  will  appear  at  the  anus  as  in  the 
cases  of  prolapse  already  described,  and  a  distinct  sulcus  may  be  felt  by 
the  finger  between  tiie  extruded  portion  and  the  mucous  membrane 
which  is  continuous  with  that  of  the  anus.  The  bottom  of  this  sulcus  or 
the  point  at  which  the  entering  portion  becomes  directly  continuous  with 
that  into  which  it  enters  may  also  be  felt  by  the  finger  if  it  is  low  enough 
down;  if  not,  it  may  be  detected  by  the  aid  of  a  soft  catheter.  This  is 
what  is  understood  by  the  third  variety  of  prolapse.  When  a  portion  of 
the  bowel  still  further  removed  from  the  anus  has  become  invaginated 
into  that  immediately  below,  the  included  portion  may  or  may  not  descend 
sufficiently  near  to  the  anus  to  be  felt  by  rectal  touch,  and  the  sulcus  may 
not  be  apparent.  This  constitutes  the  fourth  variety  or  what  is  now 
generally  known  as  intussusception.  It  is  evident  that  between  a  case  of 
prolapse  in  which  all  the  coats  of  the  rectum  appear  through  the  anus, 
and  in  which  a  sulcus  can  be  felt  by  the  finger  passed  around  the  pro- 
truded portion;  and  a  case  in  which  the  ileum  is  telescoped  through  the 
ilio-caecal  valve  and  appears  at  the  anus,  the  difference  is  one  of  degree 
and  not  of  kind. 

Of  this  condition  there  are  many  degrees,  and  almost  any  portion  of 
the  bowel  from  the  duodenum  to  the  rectum  may  become  invaginated 
into  the  portion  next  l^elow.  The  coecum  itself  may  be  so  loosened  from  its 
attachments  as  to  follow  the  same  course,  and  the  orifice  of  the  appendix 
vermiformis  may  be  detected  at  the  anus  by  the  side  of  the  orifice  of  the 
included  bowel. 

In  763  cases  of  invagination  collected  by  Bulteau,' 220  were  of  the 
small  intestine;  151  of  the  large;  and  392  ileo-caecal. 

The  mesentery  of  the  two  included  portions  is  drawn  in  with  them, 
and  by  its  attachment  and  traction  gives  to  them  a  curve  the  concavity 
of  wiiich  is  towards  the  point  of  attachment  of  the  mesentery.  For  this 
reason  the  lower  orifice  of  the  included  portion  is  not  found  in  the  axis 
of  tlie  containing  portion,  but  turned  toward  some  portion  of  its  circum- 
ference, and  is,  therefore,  often  difficult  to  detect  by  a  digital  examina- 
tion. 

'  De  I'occlusion  intestinale  au  point  de  vue  du  diagnostic  et  du  traitement. 
These  de  Paris,  1878. 


126  DISEASES    OF    THE    RECTUM    AND    ANUS. 

The  immediate  effect  of  an  invagination  is  to  interfere  with  the  pas- 
sage of  faeces,  but  seldom  to  entirely  prevent  their  passage,  for  the  faeces 
do  pass  and  in  considerable  quantity,  forced  down  through  the  con- 
striction by  the  contraction  of  the  healthy  bowel  above. 

Another  immediate  effect  which  is  due  to  constriction  of  the  blood- 
vessels in  the  included  mesentery  and  in  the  walls  of  the  included  portion, 
IS  the  transudation  of  serum  and  consequent  swelling  of  the  intestinal 
walls.  By  this  means  the  serous  surfaces  become  dark-colored,  and  the 
mucous  surfaces  become  infiltrated;  blood  is  effused  between  the  mucous 
surfaces  of  the  outer  and  middle  layers,  and  lymph  between  the  serous 
surfaces  of  the  middle  and  internal  layers,  and  after  a  time  these  become 
completely  agglutinated. 

If  the  constriction  be  sufl&ciently  severe,  the  included  portions  soon 
become  gangrenous  and  slough  away,  the  lumen  of  the  bowel  is  again 
established,  and  a  circular  cicatrix  is  left.  This  is  nature's  method  of 
cure,  and  though  life  is  by  it  saved  for  a  time,  in  the  end  the  cicatrix 
thus  formed  may  become  a  stricture  which  shall  be  more  surely  fatal  than 
the  condition  from  which  it  arose.  The  invaginated  portion  is  at  first  of 
necessity  short;  but  as  the  case  advances,  it  may  reach  to  several  feet, 
and  in  one  case'  there  is  a  reason  to  believe  that  about  four  yards  of  in-^ 
testine  came  away,  piece  by  piece,  per  mium. 

The  disease  is  twice  as  common  in  males  as  in.  females,  and  is  greatly 
more  common  in  children  than  in  adults.  In  adults  the  trouble  will 
generally  be  found  to  involve  the  small  intestine;  in  children,  the  large. 
An  invagination  of  the  small  into  the  large  intestine  begins  generally  at 
the  ileo-caecal  valve,  which  with  the  vermiform  appendix  is  carried  up 
the  ascending,  and  along  the  transverse  colon,  till  it  may  finally  reach 
the  anus  and  protrude  through  it,  the  valve  all  the  time  remaining  the 
lowest  portion.  In  these  cases  only  the  inner  tube  is  made  of  small  in- 
testine, the  middle  and  the  outer  consisting  of  the  large. 

Strangulation  is  much  more  frequent  where  the  outer  layer  is  com- 
posed of  the  small  than  where  it  is  composed  of  the  large  intestine; 
because  of  the  greater  tightness  of  the  constriction.  In  the  latter  case 
the  congestion  may  be  only  moderate  in  degree  and  the  condition  may 
last  many  weeks  without  gangrene  or  ulceration.  This  condition  is 
known  as  chronic  intussusception. 

If  sloughing  occur  at  all,  it  may  happen  at  any  time  after  the  first 
week,  generally,  however,  it  occurs  within  three  weeks,  though  it  may 
be  delayed  for  a  much  longer  time.  In  one  case^  the  separation  of  frag- 
ments of  intestine  extended  over  an  interval  of  three  years. 

In  about  one-half  of  the  reported  cases  a  favorable  termination  has 
followed  spontaneous  separation,  in  the  remainder  death  has  occurred 
« 

'  Peacock.  Path.  Trans.,  vol.  xv. 
^  Peacock,  loc.  cit. 


PROLAPSE.  127 

after  a  longer  or  shorter  interval.  Several  pathological  changes  may 
occur.  The  peritonitis  which  serves  to  unite  the  serous  surfaces  of  the 
contained  portions  may  become  general  and  cause  death.  The  ensheath- 
iug  portion  may  become  ulcerated  and  perforated,  allowing  of  the  extra- 
vasation of  faeces.  The  ulceration  may  perhaps  be  due  to  the  lateral 
pressure  of  the  end  of  the  contained  portion  against  the  side  of  the 
cylinder  which  contains  it. '  Separation  by  sloughing  leaves  the  upper  end 
of  the  ensheathing  portion  united  with  the  lower  end  of  the  healthy 
bowel,  and  results  in  complete  amputation  of  the  contained  portion. 
Extravasation  may  also  occur  from  a  deficiency  in  this  union  at  the  time 
when  separation  occurs. 

The  causes  of  invagination  are  not  as  yet  perfectly  understood.  It  is 
easy  to  understand  how  in  the  effort  which  the  intestine  makes  to  relieve 
itself  of  a  polypus  or  other  tumor  by  its  vermicular  action,  not  only  the 
growth  itself  may  be  extruded,  but  also  the  portion  of  the  bowel  to  which 
it  is  attached;  and  polypus  is  one  of  the  recognized  causes  of  this  condi- 
tion. But  in  the  great  majority  of  cases  no  such  palpable  cause  is  to  be 
detected.  Except  in  the  case  of  a  tumor  it  is  probably  always  an  accident 
of  sudden  occurrence  dependent  upon  some  violent  action  in  that  part  of 
the  bowel.  A  collection  of  gas  causing  an  undue  dilatation  in  one  part 
of  thfe  intestine,  combined  with  a  violent  movement  of  the  abdominal 
muscles,  and  a  peristaltic  movement  in  the  portion  just  above  that  which 
ii  distended,  might,  it  is  easily  understood,  cause  the  accident.  So,  also, 
might  any  interference  with,  or  undue  violence  in,  the  rhythmic  action 
of  natural  peristalsis,  by  which  the  bowel  in  successive  portions  is  first 
shortened  and  dilated  by  contraction  of  the  longitudinal  fibres,  and  then 
narrowed  and  elongated  by  the  contraction  of  the  circular  fibres.  Since 
the  wave  of  peristaltic  action  is  constantly  passing  from  above  downwards, 
it  may  easily  happen  that  a  narrowed  portion  may  under  unfavorable  cir- 
cumstances be  caught  in  a  dilated  portion  just  below,  and,  once  engaged, 
the  exaggeration  of  the  condition  becomes  natural  and  easily  understood. 
It  is  to  such  explanations  as  this  that  we  have  to  look  in  the  absence  of 
any  palpable  cause. 

Symptoms. — An  invagination  will  cause  a  very  diflEerent  train  of 
symptoms,  according  to  the  part  of  the  bowel  affected  and  the  intensity 
of  the  constriction.  As  a  rule,  the  symptoms  are  more  acute  and  severe 
in  invagination  of  the  small  intestine,  and  are  more  chronic  in  the  large, 
because  the  constriction  is  more  intense  in  the  former  than  in  the  latter; 
but  an  invagination  of  the  small  intestine  may  approach  in  symptoms 
and  chronicity  to  one  of  the  large,  and  vice  versa. 

Wherever  the  constriction  be  located,  its  first  symptom  is  generally  a 
sharp  attack  of  pain  in  the  abdomen,  coming  on  suddenly,  and  often  in 
the  midst  of  perfect  health.     There  is  nothing  characteristic  in  this 


Aitken:  Pract.  of  Med.,  vol.  ii. 


128  DISEASES   OF   THE   EECTUM    AND    ANUS. 

pain.  It  may  pass  off  after  a  few  hours  and  again  return;  it  may  or  may 
not  be  accompanied  by  vomiting  at  the  start;  it  is  sometimes  relievable 
by  dii-ect  pressure,  and  it  is  not  at  first  accompanied  by  any  tenderness 
of  the  abdomen. 

Change  in  the  character  of  the  evacuations  is  also  a  symptom  com- 
mon to  the  disease  lu  any  part.  After  the  onset  there  will  still  be  a  dis- 
charge of  the  contents  of  the  bowel  below  the  constriction,  and  a  certain 
amount  of  fseces  may  still  leak  through  the  invagination.  Instead  of  the 
natural  passages,  however,  the  appearance  of  bloody  stools  is  a  very  com- 
mon occurrence,  the  blood  coming,  as  has  already  been  explained,  from 
the  congested  and  swollen  mucous  membrane  of  the  outer  and  middle 
portions.  There  is  also  present  at  times  a  dysenteric  discharge  and  a 
good  deal  of  tenesmus. 

By  careful  manual  examination,  a  tumor  can  generally  be  discovered 
in  the  abdomen,  which  may  be  characteristic  enough  to  form  a  basis 
for  the  diagnosis;  but  this  may  be  concealed  by  the  presence  of  much 
fat,  or  by  a  general  distention  of  the  abdomen  with  gas.  The  tumor  is 
cylindrical,  and  may  be  movable  under  the  hand  from  its  own  peristaltic 
action,  or  it  may  be  seen  to  change  its  position  from  day  to  day  as  the 
invagination  gradually  advances,  and  more  and  more  of  the  bowel  be- 
comes involved. 

The  other  symptoms  depend  in  great  measure  upon  the  severity 
of  the  strangulation,  and,  as  has  been  said,  are  more  marked  when  the 
small  intestine  is  implicated.  In  such  cases,  the  symptoms  rapidly  in- 
crease in  severity.  There  may  or  may  not  be  considerable  febrile  action; 
the  abdomen  soon  becomes  tender  to  the  touch;  there  is  almost  complete 
obstruction,  or  else  only  the  passage  of  bloody  mucus;  the  patient 
rapidly  sinks,  and  the  history  ends  either  in  death  or  in  the  slough- 
ing of  the  included  part.  The  latter  is  shown  by  a  re-establishment  of 
the  calibre  of  the  bowel,  and,  therefore  of  the  passages;  by  an  abatement 
of  all  the  worst  symptoms,  and  finally  by  the  appearance  of  larger  or 
smaller  pieces  of  gangrenous  intestine  in  the  passages. 

The  existence  and  the  early  appearance  of  faecal  vomiting  have  been 
given  as  points  in  favor  of  the  diagnosis  of  intussusception  of  the  small 
rather  than  of  the  large  intestine,  but  they  point  rather  towards  complete 
obstruction  than  to  the  particular  seat  of  the  obstruction. 

In  invagination  of  the  large  intestine,  the  general  history  of  the  case 
is  that  of  a  more  chronic  trouble.  The  pain  is  less  severe  and  the  par- 
oxysms separated  by  longer  intervals;  the  faecal  evacuations  are  larger, 
and  the  dysenteric  symptoms  are  more  pronounced;  vomiting  is  variable, 
and  after  a  time  often  stercoraceous.  This  state  may  continue  for -several 
weeks  before  death  results  from  gradual  exhaustion  or  from  the  super- 
vention of  acute  strangulation.  The  history  of  a  case  of  chronic  inva- 
gination may  at  any  time  be  cut  short  by  the  occurrence  of  a  general 


PROLAPSE.  129 

acute  perionitis,  and  this  is  particularly  apt  to  happen  at  the  time  of 
the  separation  of  the  slough. 

Diagnosis. — In  any  case  in  which  the  invaginated  portion  descends 
near  enough  to  the  anus  to  be  felt  by  digital  examination,  the  diagnosis 
is  easy  to  the  surgeon  of  ordinary  care  and  intelligence  who  has  studied 
the  symptoms  which  infallibly  point  in  the  direction  of  intestinal  occlu- 
sion. But  when  such  an  examination  has  been  made  with  a  negative  re- 
sult, beyond  the  fact  that  occlusion  exists  tho  surgeon  may  be  completely 
at  a  loss.  Under  such  circumstances  the  differential  diagnosis  rests  be- 
tween the  following  conditions;  1.  Invagination;  2.  Volvulus;  3.  Stric- 
ture; 4.  Concealed  internal  hernia;  5.  Pressure  from  without  the  bowel  by 
tumors  etc. ;  6.  Obstruction  from  foreign  bodies,  as  calculi,  indurated 
faeces,  etc. ;  7.  Peritonitis  from  perforation.  It  may  be  as  well  to  state  at 
once  that  in  these  cases  the  differential  diagnosis  will  often  be  impossible, 
and  then  goon  to  throw  what  light  upon  the  question  modern  science  has 
made  available.  It  is  a  good  plan  to  divide  all  cases  of  intestinal  obstruc- 
tion into  the  acute  and  the  chronic.  An  acute  case  will  generally  be 
either  an  invagination,  a  volvulus,  or  an  internal  hernia.  Duplay'  also  has 
called  attention  to  the  fact  that  a  peritonitis  from  perforation  may  cause 
all  the  symptoms  of  an  acute  occlusion  and  has  given  the  chief  points  in 
the  diagnosis  of  that  affection.  In  peritonitis  the  vomiting  seldom  be- 
comes faecal  but  remains  bilious  to  the  end;  the  constipation  is  less  marked 
and  the  patient  generally  passes  gas  and  liquid  faeces  or  small  quantities 
of  solid  matter;  the  tympanites  is  also  less  marked,  and  the  coils  of  intes- 
tine are  less  pronounced;  the  pain  begins  with  great  severity  at  one  point 
and  extends  over  the  whole  abdomen  (the  same  thing  may  happen  in  acute 
obstruction,  but  in  such  cases  the  other  symptoms — faecal  vomiting,  abso- 
lute constipation,  absence  of  the  passage  of  gas  per  atmvi — are  all  equally 
severe,  while  in  peritonitis  they  do  not  correspond  in  severity  with  the  in- 
tensity of  the  pain);  the  temperature  is  elevated  in  peritonitis  and  normal 
or  even  less  than  normal  in  obstruction. 

Having  then  excluded  peritonitis  from  perforation,  the  diagnosis  in 
liny  acute  case  will  rest  between  invagination,  volvulus,  and  internal  her- 
nia. Invagination  is  indicated  by  the  signs  ot  partial  occlusion,  by  the 
moderate  tympanites,  by  the  bloody  stools  mixed  with  mucus,  the  tenes- 
mus, and  the  presence  of  the  tumor.  The  diagnosis  between  volvulus  and 
internal  hernia  will  generally  be  impossible  except  as  tiie  history  may  point 
to  antecedent  peritonitis,  or  to  a  hernia  which  has  ceased  to  come  down; 
or  as  the  careful  exploration  of  the  abdomen  by  palpation  and  of  the  pel- 
vis by  rectal  and  vaginal  touch  may  show  the  existence  of  an  induration 
or  resistance  limited  to  one  point. 

In  other  words,  in  any  acute  case  of  occlusion  the  existence  of  invagi- 

'  Duplay:  Dii  Traitement  Chirurgical  de  I'Occlusiou  Intestiual.   Arch.  Oenl.  de 
Med.,  Dec.,  1879. 
9 


130  DISEASES    OF    THE    RECTUM    AND    ANUS. 

nation  may  be  decided  by  the  presence  or  absence  of  its  peculiar  symp- 
toms, and  if  excluded  the  diagnosis  rests  either  with  yoIvuIus  or  internal 
hernia,  but  with  which  it  may  be  impossible  to  decide. 

In  a  case  of  chronic  intestinal  occlusion,  the  diagnosis  rests  between 
invagination,  occlusion  by  the  .pressure  of  solid  or  fluid  tumors  outside 
the  bowel,  stricture  of  the  intestine,  abnormal  adhesions  of  the  bowel,  and 
obstruction  by  foreign  bodies  within  the  bowel,  such  as  biliary  calculi, 
indurated  faeces,  tumors,  etc.  The  easiest  of  these  to  diagnosticate  is 
that  which  comes  from  the  pressure  of  a  tumor  without  the  bowel. 
Chronic  invagination  may  be  made  out  by  the  symptoms  already  given. 
For  the  symptoms  of  stricture,  we  must  refer  the  reader  to  the  chapter 
on  that  subject,  and  these  symptoms  are  much  the  same  whether  the 
obstruction  be  due  to  a  narrowing  of  the  calibre  of  the  bowel  by  a  de- 
posit in  its  wall,  or  to  the  presence  of  a  foreign  body,  or  abnormal  ad- 
hesions of  the  peritoneum  which  cause  acute  flexures  and  obstructions 
in  its  calibre. 

It  will  thus  be  seen  that  the  differential  diagnosis  is  shrouded  in 
difficulty,  and  that  the  difficulty  is  rather  greater  in  a  case  of  chronic 
than  of  acute  obstruction.  A  well-marked"  case  of  invagination,  whether 
acute  or  chronic,  is,  however,  the  easiest  of  all  the  forms  of  occlusion 
to  distinguish,  and  the  diagnosis  can  generally  be  made  with  sufficient 
approach  to  certainty  to  guide  the  surgeon  in  the  selection  of  his  plan 
of  treatment. 

Treatment. — It  is  evident  that  the  treatment  of  the  conditions  we 
have  been  describing  must  differ  in  every  particular  from  that  of  those 
previously  described.  When  the  invagination  has  occurred  in  the  rec- 
tum, that  is,  when  the  upper  part  of  the  rectum  has  become  telescoped 
into  the  lower,  and  has  appeared  as  a  prolapsed  mass  outside  of  the  anus, 
the  case  may  still  be  relievable  by  the  methods  of  reduction  and  taxis. 
The  mass  must  be  replaced  by  a  process  exactly  the  reverse  of  the  one 
by  which  it  came  down,  the  most  dependent  portion  being  first  carried 
into  the  body,  and  the  entanglement  unfolded  in  this  way.  In  a  child, 
with  the  assistance  of  anaesthesia,  the  inverted  position,  and  gentle 
manipulation  with  the  fingers  or  possibly  a  soft  bougie,  this  may  some- 
times be  accomplished  where  the  point  of  constriction  is  low  down  near 
the  anus.  Prall '  reports  a  case  where  replacement  was  successfully 
accomplished  by  manipulation  with  the  tube  of  a  stomach-pump,  though 
the  mass  could  only  just  be  felt  in  the  rectum. 

In  cases,  whether  of  adults  or  children,  where  the  constriction  is 
still  higher  in  the  intestine,  and  manipulation  with  the  hand  or  bougie 
is  out  of  the  question,  various  other  mechanical  means  may  be  tried  with 
a  prospect  of  success.  These  consist  in  applying  indirect  pressure  to 
the  invaginated  portion,  and  to  the  constricting  pai't  by  means  of  copi- 

'  Brit.  Med.  Joum.,  July  31st,  1880. 


PROLAPSE.  131 

ous  injections  of  water  or  air,  but  it  should  be  understood  that  they  are 
only  applicable  to  cases  affecting  tiie  large  intestine  alone,  and  the  lower 
down  in  the  large  intestine  the  constriction  may  be,  the  better  is  the 
prospect  of  their  success.  In  cases  of  this  kind,  the  mechanical  treat- 
ment may  be  assisted  by  the  previous  administration  of  opium  and  bella- 
donna in  full  doses,  the  one  to  quiet  peristalsis,  the  other  to  relax  the 
unstriped  muscular  fibres  of  the  intestine.  To  these  means  may  be 
added  the  reversal  of  position  and  anaesthesia,  and  then  the  copious 
injection  of  large  quantities  of  warm  fluid,  or  of  air  by  means  of  a  bel- 
lows, may  in  a  few  cases  be  successful. 

The  following  case  illustrates  the  method  of  treatment  by  injection, 
and  what,  under  favorable  circumstances,  may  be  accomplished  by  it.' 

Case  XIII. — A  well-nourished  infant,  seven  months  old,  was  in  per- 
fect health  till  noon  of  the  day  of  attack,  when  she  sud'denly  screamed, 
and  immediately  afterward  became  pale,  cold,  and  collapsed.  She  was 
put  into  a  warm  bath,  after  which  she  lay  quietly  in  the  nurse's  arms 
for  an  hour  and  a  half,  the  bowels  acting  slightly  once  or  twice.  At  3 
P.M.,  the  child  had  become  warmer,  and  was  sleeping  quietly,  occasion- 
ally, however,  waking  up  with  a  scream,  and  drawing  up  her  legs  with 
an  expression  of  severe  pain.  There  was  occasional  vomiting,  and  at  6 
P.M.,  two  passages  of  bloody  mucus.  At  11  p.m.,  a  distinct  but  ill-de- 
fined oval  tumor,  about  an  inch  and  a  half  in  its  longest  diameter,  could 
be  felt  through  the  parietes,  at  a  spot  two  inches  to  the  left  of  the  umbilicus. 
A  considerable  quantity  (perhaps  a  drachm)  of  dark  blood  came  away, 
and  it  was  determined  to  distend  the  large  intestine  with  thin  gruel. 
The  child  was  put  thoroughly  under  the  influence  of  chloroform,  and 
placed  on  the  table  with  the  nates  well  raised  on  a  pillow.  The  gruel  was 
slowly  injected  by  means  of  a  Higginson's  syringe,  the  upper  part  of  the 
nozzle  being  pressed  firmly  against  the  anus  to  prevent  any  from  escap- 
ing. After  a  pint  or  more  had  been  injected,  the  abdomen  became 
tense,  and  the  distended  bowel  could  be  felt  like  a  hard  rope  an  inch  in 
diameter,  across  the  upper  part  of  the  abdomen,  almost  as  far  as  the 
right  iliac  region,  and  considerable  force  would  have  been  required  to 
inject  any  more  of  the  fluid.  When  the  nozzle  of  the  syringe  was  re- 
moved, a  portion  of  the  gruel  escaped,  and  soon  afterwards  a  much  larger 
quantity.  The  child  slept  well  at  intervals  during  the  night,  took  the 
breast  well,  and  there  wjis  neither  vomiting  nor  pain.  Next  morning 
the  skin  was  a  little  hot  and  the  pulse  a  little  quick,  and  one  small 
healthy  motion  had  been  passed.  The  tumor  which  had  been  felt  in  the 
abdomen  had  disappeared.  At  1  p.m.,  all  the  feverish  symptoms  had 
disappeared,  and  the  child  had  passed  a  copious  motion  of  green  color, 
and  there  had  been  no  pain  or  spasm.  At  4  p.m.,  there  was  another 
large  motion  of  the  same  character.     From  this  time  the  child  appeared 

'  Dr.  N.  P.  Blaker,  Brit.  Med.  Journ.,  Jan.  11th,  1879. 


132  DISEASES    OF   THE    EECTUM    AND    ANUS. 

in  perfect  health,  bnt  the  motions  retained  their  unhealthy  look  for  four 
days  longer.  " 

The  success  of  this  treatment  undoubtedly  depended  in  a  grieat  mea- 
sure upon  the  speed  with  Avhich  it  was  adopted  before  reduction  became 
difficult  from  strangulation. 

Instead  of  warm  gruel  the  enema  may  consist  of  simple  water,  or  of 
soda-water  from  a  siphon,  or  of  a  portion  of  a  seidlitz  powder,'  the  idea 
in  the  latter  case  being  to  gain  the  distention  by  the  gas  as  well  as  by  the 
water.  A  good  formula  when  it  is  desired  to  make  use  of  the  pressure 
of  gas  is  two  parts  of  a  solution  of  bicarbonate  of  soda,  and  one  of  tartaric 
acid  injected  separatel}'.  There  are  now  many  cases  recorded  in  which 
these  means  have  been  successful,  and  the  relief  following  such  a  proce- 
dure has  been  instantaneous,  but  as  a  rule  injections  of  fluid  are  more 
easily  managed,*the  amount  of  pressure  produced  by  them  better  gauged, 
and,  therefore,  they  are  safer. 

There  is  much  to  be  said  against  the  practice  of  trying  to  relieve  the 
condition  of  distention  by  puncture  of  the  intestine,  though  Broadbent 
reports  a  very  successful  case  in  which  cure  was  affected  by  that  means. 
The  danger  is  that  f^cal  extravasation  may  occur,  and  to  guard  against 
this  he  offers  the  following  suggestions:  1,  To  secure,  if  possible,  absolute 
freedom  from  peristalsis  by  an  extra  dose  of  opium.  2,  To  select,  if  pos- 
sible, a  coil  of  intestine  which  shall  contain  only  gas  and  not  liquid. 
This  will  be  found  (if  anywhere)  in  the  jejunum,  and  therefore  above  and 
not  below  the  umbilicus.  An  indispensable  condition  is  that  scarcely  any 
food  shall  have  been  taken  during  the  entire  attach.  3,  To  pierce  the  coil 
exactly  at  its  most  convex  part.  The  abdomen  should  be  carefullly 
watched  for  some  time  at  every  visit,  and  especially  before  the  operation. 
In  some  cases  where  the  walls  are  thin  the  outlines  of  various  coils  may 
be  traced  even  in  repose;  but  this  will  be  more  distinct  when  peristalsis 
is  provoked  by  pressure  or  manipulation  of  any  kind;  it  will  be  seen  also 
which  coils  shift  and  which  keep  the  same  position  when  contracting. 
The  spot  chosen  for  puncture  should  be  as  near  as  possible  over  the 
centre  of  a  coil  which  does  not  roll  about,  and  by  preference  in  the  linea 
alba.  4,  To  exercise  great  care  and  patience  during  the  escape  of  gas. 
The  needle  should  be  held  lightly  but  rather  firmly,  perpendicular  to  the 
abdominal  wall,  and  should  not  be  allowed  to  follow  too  freely  the  rolling 
of  th§  coil  of  intestine.  As  the  gas  escapes  from  the  coil  which  has  been 
punctured,  it  will  collapse,  and  the  flow  from  the  needle  will  cease;  very 
soon,  however,  the  air  in  the  intestine  will  distribute  itself  and  enter  the 
empty  portion,  when  it  will  again  escape.  This  may  be  aided  Ijy  gentle 
manipulation  and  pressure.  Should  the  tube  get  blocked,  aspiration  may 
free  it;  but  it  is  safer  to  drive  a  little  air  through  the  tube  into  tlie  bowel 


'  Case,  Dr,  Morton,  Practitioner,  July,  1875. 


PKOLAPSB.  /33 

than  to  exert  powerful  suction  which  may  draw  the  mucous  membrane 
against  the  point  of  the  needle. 

Dr.  Broad  bent,  in  spite  of  the  rules  for  its  use  which  he  has  so  carefully 
laid  down,  believes  that  puncture  can  relieve  obstruction  only  very  ex- 
ceptionally. His  own  experience  leads  him  to  recommend  it  as  a  pallia- 
tive, and  he  suggests  that  it  may  be  a  useful  preliminary  to  inflation, 
manipulation,  suspension  in  the  inverted  position,  etc.,  in  the  treatment 
of  intussusception. 

The  chief  hope  of  relieving  an  invagination,  however,  lies  in  prompt 
and  efficient  surgical  interference  by  opening  the  abdomen.  The  pro- 
priety of  such  a  course  has  in  the  last  few  years  been  the  subject  of  much 
argument.  In  its  favor  have  been  adduced  the  rarity  of  ultimate  recov- 
ery from  the  disease  even  after  sloughing  of  the  included  portion  and 
temporary  relief;  the  fact  that  when  the  large  intestine  is  affected  the 
bowel  may  remain  in  a  comparatively  healthy  state  for  weeks;  and  above 
all  the  actual  saving  of  life  which  has  now  sufficiently  often  followed  the 
performance  of  the  operation  to  attest  its  undoubted  value.  Against  the 
operation  still  stand,  however,  the  difficulty  of  positive  diagnosis,  espe- 
cially early  in  the  disease;  the  speedy  formation  of  such  adhesions  as  will 
prevent  reduction  even  after  the  abdomen  has  been  opened,  and  the  early 
supervention  of  gangrene  which  renders  reduction  improper;  and  the 
comparative  frequence  of  spontaneous  recoveiy  by  sloughing. 

At  the  present  time  it  is  admitted  that  in  cases  of  acute  or  chronic 
invagination,  where  the  diagnosis  is  reasonably  certain,  and  where  the 
means  of  relief  which  have  been  enumerated  have  been  tried  and  failed, 
the  abdomen  should  be  opened.  The  discussion  at  present  has  changed 
its  bearings  to  the  question  of  abdominal  section  where  the  diagnosis  as 
to  tlie  form  of  obstruction  cannot  be  arrived  at.  The  surgeon  having 
arrived  at  this  conclusion,  no  time  is  to  be  lost;  for  success,  if  the  oper- 
ation be  successful,  will  depend  more  than  anything  else  upon  the  time 
at  which  the  operation  is  done. 

The  operation  of  laparotomy  or  opening  the  abdominal  cavity  is  to  be 
performed  as  follows.  The  incision  should  be  about  five  inches  long,  in 
the  linea  alba  above  the  umbilicus.  The  tissues  should  be  divided  slowly 
and  all  bleeding  should  bo  stopped  before  the  peritoneum  is  opened  on  a 
director  to  an  extent  equalling  the  opening  in  the  skin.  The  scat  of  the 
obstruction  is  to  be  sought  for  by  first  noticing  the  condition  of  the 
caecum.  If  tliis  bo  flaccid,  the  obstruction  is  in  the  small  intestine,  if  it 
be  distended  it  is  in  the  large.  If  the  ciecum  be  found  undistended  the 
hand  is  to  be  passed  gradually  along  the  small  intestine,  till  the  obstruc- 
tion is  encountered;  if  the  opposite  condition  obtains,  tlio  ascending, 
transverse,  and  descending  colon  are  to  be  successively  examined. 

When  the  invagination  has  been  found,  it  should  be  unfolded  as 
Hutchinson  suggests,  rather  by  expressing  the  included  portion  out  of  its 


134  DISEASES    OF   THE    RECTUM    AND   ANUS. 

sheath  from  below  upwards  than  by  traction  upon  it  from  above.  If  the 
bowel  shoul(J  be  found  perforated,  or  gangrenous  in  any  part  so  that 
perforation  seems  probable,  an  artificial  anus  is  to  be  formed  by  stitch- 
ing the  bowel  to  the  lowest  part  of  the  abdominal  wall. 


NON-MALIGNANT   GRO^VTH8   OF   THE    EECTTUM   AHD    ANUS.  135 


CHAPTER  Till. 

NON-MALIONANT   GROWTHS   OF  THE   RECTUM   AND   ANUS. 

Polypus.— Definition. — Hypertrophy  of  Villi. — Characteristics. — Villous  Tumor. 
— Adenomatous  Polypus. — Fibrous  Polypus. — Structure;  Characteristics. — 
Symptoms  of  Polypus. — Diagnosis. — Diagnosis  from  Malignant  Disease. — 
Treatment. — Vegetations. — Definition. —  Description.  — Microscopic  Appear- 
ances.— Relation  to  Syphilis. — Symptoms  of  Vegetations. — Diagnosis. — Treat- 
ment.— Condylomata. — Distinction  between  Condylomata  and  Vegetations. — 
Description  —Syphilitic  and  Non-syphilitic  Condylomata. — Benign  Fungus. 
— Gummata.— Rarity  and  Literature. — Ano-rectal  Syphiloma. — Definition  of 
Foumier,  —  Fibromata.  —  Lipomata.  —  Characteristics.  —  Enchondromata. — 
Cysts. — Dermoid  Growths. — Characters.  —  Pilo-Nidal  Sinus.  —  Hydatids. — 
Foetal  Inclusions. — Spina  Bifida.— Congenital  Cysts. 

Under  this  head  will  be  included  polypus,  vegetations,  condylomata, 
benign  fungus,  gummata,  ano-rectal  syphiloma,  fibromata,  lipomata, 
enchondromata,  and  the  various  forms  of  cysts. 

Polypus. — A  polypus  may  be  defined  as  a  benign  tumor  composed  of 
one  or  more  of  the  normal  elements  of  the  wall  of  the  rectum;  an  hy- 
pertropliy  either  of  the  mucous  membrane  or  of  the  submucous  connec- 
tive tissue.  Those  which  are  composed  of  the  elements  of  the  mucous 
membrane  are  known  and  generally  spoken  of  as  *'soft"  polypi;  while 
those  into  which  the  submucous  connective  tissue  enters  are  known  as  the 
"hard  "  or  fibrous.  In  many  works  the  former  class  are  spoken  of  as 
the  polypi  of  childhood  and  the  latter  as  those  of  adult  age — a  classifica- 
tion of  little  practical  value. 

The  mucous  membrane,  as  has  been  shown,  is  composed  of  villi,  of 
the  follicles  of  Lieberkuhn  or  tubular  glands,  and  of  occasional  closed  or 
solitary  follicles.  A  polypus  composed  of  an  hypertrophy  of  the  villi  is 
well  represented  in  Fig.  41. 

A  polypus  of  this  variety  may  reach  tlie  size  of  a  pigeon's  eg^,  it  is 
soft  to  the  feel,  and  has  a  shaggy  or  cauliflower  surface.  On  section  the 
cut  surface  is  of  grayish-red  color,  the  substance  of  tlie  growth  homoge- 
neous, and  the  fluid  which  may  be  forced  from  it  by  pressure  will  be 
found  to  be  full  of  cylindrical  epithelium.     A  microscopic  examination 


136 


DISEASES    OF   THE    RECTUM    AND    ANUS. 


sliows  it  to  be  composed  of  long  fine  papillae  bifurcated  at  their  extremities 
and  covered  by  cylindrical  epithelium.' 

Although  the  polypi  are  generally  small,  Dr.  Goodsall  has  reported  a 
case  from  St.  Mark's  Hospital/  in  which  the  tumor  attained  the  size  of 
an  orange.  It  was  rough  and  tuberculated  on  the  surface,  and  was  at- 
tached to  the  rectal  wall  by  a  pedicle  long  enough  to  permit  of  its  extru- 
sion from  the  anus  without  pain.  It  was  attended  by  a  frequent,  copious, 
watery  discharge,  but  never  by  any  very  free  haemorrhage  at  one  time, 
and  the  patient  showed  no  emaciation. 

Villous  polypus  {grsmwlar -pa,pi\\oma,f  Gtosselin;   villous   tumor,   Cur- 


Fig.  41— Rectal  Polypus  (Esmarcta). 

ling;  villous  polypi,  Esmarch;  ''peculiar  bleeding  tumor,"  Quain). — Figs. 
43  and  43. 

It  is  a  question  whether  this  form  of  growth  should  be  classified  with 
the  polypi  already  described,  or  with  the  warty  growths,  whose  descrip- 
tion is  to  follow.  It  consists  of  an  hypertrophy  both  of  the  villi  and  of  the 
follicles  of  Lieberkuhn,  with  a  centre  of  connective  tissue  and  generous 
vascular  supply.  According  to  the  description  given  by  Dr.  A.  Clark^  of 
a  specimen  in  the  London  Hospital  Museum,  the  tumor  is  "  essentially  an 
outgrowth  of  dense  areolar  tissue,  permeated  by  blood-vessels,  and  assum- 


'  Lucke:  Die  Geschwiilste.     Handbuch   der  allgemeinen  und  speciellen  Chi 
nirgie.     Pitha  u.  Billroth,  p.  250. 
5  Lancet,  May  21st,  1881.  p.  82a 
^  Curling,  p.  85. 


NON-MALIONANT   OHOWTH8    OF   THE    RECTUM    AND   ANUS. 


137 


ing  a  papillary  form,  the  papillae  being  flattened  and  curled  so  as  to  rep- 
resent hollow  cylinders,  and  being  clothed  with  layers  of  epithelium,  the 
free  layers  being  cylindrical. " 

These  tumors  are  very  rare;  they  have  the  feel  of  a  large  warty  poly 
pus  with  cauliflower  surface;  are  of  red  color;  bleed  easily;  are  of  rela- 
tively slow  grpwth,  existing  in  Gowland's  case  several  years.  They 
adhere  to  the  wall  of  the  rectum  by  a  pedicle,  sometimes  composed  chiefly 
of  mucous  membrane,  and  at  others  large,  short,  and  fleshy. 


Fia.  42.— Villoxis  Polypus  (Bryant). 

The  pedicle  may  be  absent  (Curling) ;  and  the  growth  will  vary  in  struc- 
ture according  to  the  proportion  of  its  different  elements.  It  may  reach 
the  size  of  an  orange ' ;  it  is  found  only  in  adults  or  in  old  persons,  and 
the  symptoms  are  the  same  as  those  caused  by  other  polypi;  viz.,  dis- 
charge and  haemorrhage:  but  the  haemorrhage  is  not  a  constant  symp- 
tom, and  varies  greatly  in  frequency  and  amount  in  different  cases. 

The  adenomatous  polypi,  or  those  developed  from  the  glands  of  the 
mucous  membrane,  are  well  shown  in  Fig.  44. 


*  Syme:  Diseases  of  the  Rectum,  2d  ed.,  p.  82. 


138 


DISEASES    OF   THE   EECTUM   AND    ANUS. 


These  may  be  due  either  to  an  hypertrophy  of  the  follicles  of  Lieber- 
kuhn  or  to  an.  hypertrophy  of  the  closed  follicles.  They  occur  most  fre- 
quently in  young  persons;  are  generally  of  the  size  of  a  small  plum, 
rarely  reach  that  of  a  pear,  and  yet  Esmarch  reports  one  weighing  four 
pounds.*  They  are  very  vascular  tumors,  and,  therefore,  of  reddish 
color;  they  are  sometimes  smooth  on  the  surface,  but  oftener  mammil- 
lated,  like  a  strawberry,  and  are  attached  by  a  pedicle,  most  often  to  the 
posterior  wall,  but  occasionally  to  the  sides  of  the  rectum,  and  at  a  point 
generally  within  reach  of  the  finger,  but  sometimes  higher  up.  They 
may  indeed  occur  anywhere  along  the  large  intestine  as  high  up  as  the 
ileo-caecal  valve. 

The  pedicle  is  generally  large  and  short,  and  not  long  and  slender  as 


Fig.  44.— Glandular  polypus  (Esmarch). 

in  the  case  of  the  fibrous  polypi  soon  to  be  described;  but  there  are  fre- 
quent exceptions  to  this  rule,  and  these  tumors  will  sometimes  be  spon- 
taneously expelled  by  rupture  of  the  slender  pedicle  in  defecation. 

The  pedicle  is  also  sometimes  double  (Smith).  It  consists  of  mucous 
membrane  covering  the  vessels,  which  carry  the  blood  to  the  tumor,  and 
return  it  again — an  artery  and  generally  two  veins,  but  when  the  tumor 
is  very  large,  sometimes  two  arteries  and  a  collection  of  veins. 

Poljrpi  which  consist  of  an  hypertrophy  of  the  closed  follicles  of  the 
rectum  are  often  found  in  considerable  numbers.     Fochier*  removed  sev. 


>  Op.  cit.,  p.  176-177. 
«  Molliere,  p.  362.     Note. 


NON-MALIGNANT    GBOWTHS    OF   THE   RECTUM    AND    ANUS.  139 

eral  hundred  of  them  from  a  patient  aged  eighteen,  and  Richet '  from 
sixty  to  a  Imndred  in  a  man  aged  twenty -one.  Van  Buren  *  speaks  of  the 
same  condition,  adopting  Broca's  name  of  "polyadenomata."  To  this 
variety  of  polypus  belong  also  certain  cysts  (closed  follicles),  distended 
by  viscid  and  transparent  fluid;  and  Bathurst  Woodman  has  reported 
one  such  case  in  which  the  cyst  was  lined  by  a  membrane  similar  to  peri- 
toneum. 

On  section,  these  adenomatous  polypi  are  found  to  contain  much  vis- 
cid fluid,  full  of  cylindrical  epithelium  and  rudimentary  glandular  tubes. 
Under  the  microscope  a  vascular  stroma  of  connective  tissue  will  be 


Fio.  45.— Vertical  section  of  glandular  polypus  (Esmarcb). 

found,  in  wliich  there  are  enlarged  glandular  tubes  sometimes  branching 
at  their  extremities;  and  also  cystoid  spaces  filled  with  reddish  viscid 
fluid  (Esmarch). 

The  microscopic  appearances  of  a  section  of  such  a  polypus  are  shown 
in  Fig.  45. 

The  hard  or  fibrous  polypus  (sarcomatous  poljrpus,  Esmarch)  which  is 
composed  j)rimarily  of  the  elements  of  the  submucous  connective  tissue,  is 
much  rarer  than  the  soft  variety,  and  is  most  commonly  found  in  adults, 
where  it  may  be  isolated  or  multiple.     It  is  chiefly  composed  of  fibrous 

•  Traite  Prat.  d'Anat.  Med.-Chirurg.    4th  ed.,  Paris,  1873. 
»Op.  cit.,  p.  103. 


14:0  DISEASES    OF    THE    BEOTUM    AND    ANUS. 

tissue,  and  resembles  tlie  uterine  fibroid;  but  it  may  contain  both,  mus- 
cular and  glandular  elements.  When  the  glandular  elements  are  filled 
with  fluid  which  resembles  glue,  these  tumors  have  been  know  as  colloid, 
and  when  cysts  are  found  filled  with  jelly-like  substance,  the  name 
myxoma  has  also  been  applied. 

These  hard  or  fibrous  polypi  vary  greatly  in  their  degrees  of  hardness 
to  the  feel,  according  to  their  turgescence  and  their  composition.  They 
may  creak  under  the  knife  on  section,  and  look  very  much  like  hyper- 
trophied  and  cedematous  skin,  or  they  may  resemble  the  better-known 
nasal  polypus  in  their  consistence. 

The  connective- tissue  fibres  are  generally  irregularly  disposed,  and 
cross  each  other  in  every  direction,  though  a  regular  stratification,  such  as 
is  seen  in  uterine  myxomata,  may  be  present  (Esmarch).  When  seen 
in  the  rectum  before  removal,  the  surface  is  red  from  their  vascularity, 
but  after  removal,  they  are  pale,  and  generally  smooth,  though  some- 
times uneven  and  irregular  in  surface,  and  covered  with  hypertrophied 
papillae.  The  mucous  membrane  is  generally  easily  stripped  off,  though 
if  there  has  been  local  inflammatory  irritation,  it  may  be  firmly  attached. 
The  vascular  supply  is  abundant,  and  distributed  both  to  the  substance 
and  surface  of  the  tumor.     This  accounts  for  their  rapid  development. 

The  pedicle  is  generally  very  slight,  and  is  formed  mechanically  by 
the  traction  of  the  growth  on  the  mucous  membrane  beneath  which  it  is 
located.  It  is  composed,  as  in  the  soft  variety,  simply  of  mucous  mem- 
brane and  blood-vessels.  There  may,  however,  in  a  case  where  the 
pedicle  has  been  formed  by  traction  upon  and  prolapse  of  all  the  coats 
of  the  boWel  by  a  tumor  located  primarily  above  the  reflection  of  the 
poritoneum,  be  a  peritoneal  cul-de-sac  within  the  pedicle. 

An  hypertrophy  and  increased  vascularity  of  the  mucous  membrane 
at  the  attachment  of  the  pedicle  has  been  noted  in  certain  cases. 

If  left  to  its  natural  course,  the  pedicle  gradually  becomes  longer  and 
more  slender,  and  finally  ruptures  in  the  act  of  defecation,  and  in  this 
way  a  patient  may  relieve  himself  of  the  growth. 

These  tumors  are  benign  in  character,  and  when  once  removed,  do 
not  generally  return  at  the  same  point.  They  may,  however,  recur,  if  not 
at  the  same  point,  at  one  very  near  it,  and  the  same  patient  may  be  re- 
lieved of  a  succession  of  them. 

Symptoms. — A  rectal  polypus  may  exist  for  many  years,  and  give  no 
sign  of  its  presence.  The  two  chief  symptoms  which  it  is  apt  to  excite 
are  haemorrhage  and  discharge.  The  haemorrhage  may  be  a  daily  occur- 
rence, or  may  be  present  only  at  long  intervals,  and  it  may  vary  in 
amount  from  a  few  drops  to  a  quantity  which  shall  cause  grave  disturb- 
ance and  alarm.  When  the  mucous  membrane  covering  the  tumor  has 
once  become  ulcerated,  the  haemorrhage  Avill  be  frequent,  and  the  dis- 
charge will  be  more  or  less  foetid.  The  vessels  are  apt  to  bleed  freely 
when  opened,  because  of  their  being  imbedded  in  fibrous  tissue,  and  of 


NON-MALIGNANT   GROWTHS   OF   THE   RECTUM    AND    ANUS.  141 

their  inability  to  contract.  When  the  tumor  is  so  high  and  the  pedicle 
80  short  as  to  be  beyond  the  grasp  of  the  sphincter,  there  is  no  suffering, 
but  after  prolapse  once  begins  to  take  place,  the  suffering  may  be  very 
severe.  The  sphincter  may  become  dilated  and  relaxed,  or  the  pedicle 
may  be  firmly  grasped  by  it  after  the  act  of  defecation,  and  a  cure  may 
result  from  the  strangulation  thus  caused. 

The  discharge  from  the  rectum  wiiich  a  polypus  may' cause  is  some- 
times extreme  in  amount  and  constant,  escaping  not  only  at  the  time  of 
defecation,  but  at  frequent  intervals  between,  and  being  of  an  excessively 
foetid  character.  This  discharge  may  by  its  irritating  qualities  cause 
secondary  congestion  of  the  rectal  mucous  membrane,  erosions  around 
the  anus,  vegetations,  constant  diarrhoea,  andtene'smus;  and  joined  with 
the  loss  of  blood  the  condition  of  the  patient  may  be  easily  mistaken  for 
that  of  chronic  dysentery  or  even  malignant  disease. 

There  are  several  points  worthy  of  attention  in  examining  a  patient 
for  this  disease.  It  is  a  good  plan,  as  suggested  by  Chassaignac,  to  first 
administer  an  enema  of  water  before  making  the  examination  tliat  the 
polypus  may  float  freely  in  the  distended  rectum.  The  finger  is,  in  the 
vast  majority  of  cases,  all  that  is  necessary  for  the  examination;  and  as 
Molli^re  suggests,  the  examination  should  be  made  from  above  downwards 
and  not,  as  is  usually  the  case,  from  below  upwards.  In  the  former  case, 
by  passing  the  finger  up  along  the  anterior  wall  and  withdrawing  it  along 
the  posterior,  the  tumor  may  easily  be  caught  in  the  descent  after  the 
pedicle  has  been  put  upon  the  stretch,  wliile,  in  the  latter  case,  it  may 
easily  be  carried  up  the  bowel  and  escape  detection  altogether. 

Diagnosis. — Haemorrhage  from  the  rectum  in  a  child,  with  or  without 
pain  on  defecation,  generally  means  polypus;  and  it  often  means  the  same 
in  an  adult,  thougli  it  will  oftener  indicate  hemorrhoids.  The  secondary 
symptoms  which  seem  to  point  to  dysentery:  the  erosions  and  vegetations, 
must  never  cause  the  original  disease  to  be  overlooked.  There  is  in  fact 
but  little  difficulty  in  the  diagnosis  of  a  polypus  in  the  vast  majority  of 
cases;  but  once  in  a  while,  where  the  attachment  is  broad  and  the  pedicle 
not  well  marked,  the  question  of  benign  or  malignant  growth  may  arise 
and  be  difficult  to  solve  except  by  the  subsequent  history  and  development 
of  the  case. 

In  the  chapter  on  cancer,  attention  will  be  called  to  tha  fact  that  the 
distinction  between  epithelioma  and  a  benign  polj'pus  of  the  adenoid 
variety  cannot  always  be  made  by  the  microscopic  examination;  and  we 
here  emphasize  the  fact  that  the  diagnosis  must  rest  rather  upon  the 
clinical  history  and  gross  appearances  than  upon  histological  investiga- 
tion of  the  growth  when  removed.  In  children,  malignant  disease  is  so 
rare  that  the  chances  are  greatly  in  favor  of  benignity.  Malignant 
growths,  moreover,  do  not  tend  to  spontaneous  extrusion  and  are  not 
pedunculated,  and  the  presence  of  a  pedicle  is  therefore  greatly  in  favor 
of  benignity.     But  given  an  adult  with  an  adenoid  polypus  which  haa 


142 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


ulcerated  and  which  is  not  pedunculated,  and  the  diagnosis  between  it 
and  malignant  disease  may  be  impossible,  either  by  the  microscope  or  the 
clinical  history;  for  the  ulcerated  and  bleeding  tumor  may  cause  a  wasting 
and  cachexia  which  strongly  resembles  cancer.  A  soft  polypus  may  also 
be  mistaken  for  an  internal  haemorrhoid  when  no  pedicle  is  present,  but 
the  point  of  attachment  is  different  in  the  two  cases. 

Treatment.— The  treatment  of  polypi  is  generally  a  simple  matter. 


H 


Fig.  46. — Vegetations  (Esmarch). 


and  consists  in  their  extirpation,  after  which  they  rarely  return.  There 
are  two  dangers  to  be  considered;  the  first  is  that  the  pedicle,  when  a 
pedicle  exists,  many  contain  large  vessels;  the  other  is  that  it  may  con- 
tain peritoneum.  The  extirpation  of  a  polypus,  which  has  come  down 
from  its  attachment  in  the  sigmoid  flexure,  has  been  followed  by  death 
from  wounding  the  peritoneum,  at  the  hands  of  no  less  a  surgeon  than 
Broca.     Where  the  pedicle  is  long  and  slender,  the  polypus  may  gener- 


HON-MAUONANT   GEOWTH8    OF  THE   RECTUM    AND    ANU8.  143 

ally  be  twisted  off  by  simple  torsion  without  danger.  It  is  generally 
safer,  however,  first  to  apply  a  ligature,  and  then  cut  away  the  tumor. 
Should  there  be  no  pedicle,  the  mass  must  be  extirpated  as  any  tumor 
would  be,  and  the  haemorrhage  which  occurs  must  be  treated  upon  gen- 
eral surgical  principles. 

Vegetations. — These  growths,  known  also  by  the  names  of  warts  and 
l){ipillomata,  may  be  defined  histologically  as  an  hypertrophy  of  the 
papillary  layer  of  the  skin  and  of  the  papillary  layer  only.  They  are 
composed  of  the  connective  tissue,  the  epithelial  covering,  and  the  blood- 
vessels which,  in  their  natural  quantities,  form  the  papilla  of  the  derma. 

The  gross  appearances  of  these  warty  growths  are  represented  in 
Fig.  46. 

Under  the  influence  of  any  of  the  exciting  causes  which  will  soon  be 
mentioned,  little  tumors  resembling  ordinary  warts  appear,  and  grow 
rapidly  till  they  reach  two  or  three  millimetres  in  size.  The  extremity  of 
the  tumor  shows  a  decided  tendency  to  branching  and  bifurcation,  and 
when  there  are  many  of  them  their  branching  extremities  may  fuse  to- 
gether and  form  a  large  flat  tumor,  which  will  be  attached  to  the  skin, 
however,  by  numerous  little  pedicles,  so  that,  if  shaved  off,  the  skin  will 
not  be  wounded  except  in  numerous  small  points  where  the  pedicles  have 
hud  each  its  independent  attachment. 

When  the  wart  is  isolated  it  is  dry,  but  when  several  are  united  they 
become  macerated  in  the  secretion  of  the  part  which  decomposes  between 
them  and  gives  rise  to  inflammatory  phenomena.  The  tumor  then  be- 
comes moist  and  foetid,  and  all  the  adjacent  parts  become  irritated. 
According  to  the  size  of  the  growths,  the  condition  of  the  patient,  the 
abundance  of  the  secretions,  and  the  irritation  to  which  they  are  origin- 
ally due,  these  vegetations  take  on  various  shapes,  and  have  been  described 
as  cockscombs,  cauliflower  excrescences,  etc.,  etc.,  but  the  elementary 
structure  of  them  all  is  the  same — an  hypertrophy  and  branching  of  the 
papillae  of  the  derma. 

On  placing  a  longitudinal  section  of  one  of  these  warts  under  the 
microscope,  the  following  structures  will  be  seen.  In  the  centre,  a 
frame-work  of  connective  tissue  composed  of  a  prolongation  of  the  papil- 
lary bodies  of  the  derma,  in  the  centre  of  this  a  vascular  loop;  the  whole 
covered  by  one  or  more  layers  of  epithelium,  the  form  and  size  of  which 
are  variable,  ajid  depend  apparently  on  several  conditions,  such  as  the 
moisture  and  dryness  of  the  parts,  and  the  amount  of  pressure  to  which 
the  growths  are  subject.  When  the  connective  tissue  is  abundant  and 
the  epithelial  layer  relatively  thin,  the  vegetations  are  dry  and  hard. 
When  the  conditions  are  reversed,  they  are  moist.  When  the  vascular 
network  is  greatly  developed,  the  tumors  are  red  and  turgescent,  and 
bleed  easily. 

The  growth  occurs  from  the  cells  of  the  proliferating  zone  between 
the  summit  of  the  papilla  and  tlie  epithelial  covering.     The  intercellular 


144  DISEASES    OF   THE    EECTUM    AND    ANUS. 

substance  of  the  connective  tissue  becomes  less  abundant,  while  the  cel- 
lular elements  increase,  and  mingle  above  with  the  epithelial  layer  and 
below  with  the  connective  tissue.  Similar  jirolif crating  zones  may  be 
seen  on  the  lateral  surfaces  of  the  ramifying  warts  and,  through  their 
medium,  the  ramifications  develop  at  the  extremity  of  the  wart,  while 
on  the  level  with  the  proliferating  zones,  tlie  capillary  loops  grow  and 
develop  by  which  the  afferent  and  efferent  vessels  communicate  (Kind- 
fleisch,  Molliere). 

These  vegetations  were  formerly  considered  as  proof  positive  of  the 
existence  of  syphilis,  and  even  of  sodomy,  and  were  treated  as  such. 
Molliere  '  relates  how,  at  the  time  of  Dionysius,  there  was  a  special  hos- 
pital at  Home  for  the  treatment  of  these  growtlis;  and  Dionysius  himself 
tells  how  the  surgeons  spared  neither  the  iron  nor  the  fire,  and  were  not 
moved  to  pity  by  the  cries  of  the  patients,  inasmuch  as  this  disease  was 
the  result  of  unnatural  intercourse  between  man  and  man. 

The  same  false  idea  has  lasted  until  the  present  time,  and  is  even  now 
far  from  unpopular;  and  yet  tlie  independence  of  these  growths  upon 
syphilis  would  seem  to  be  beyond  question,  except  to  the  extent  that  any 
syphilitic  sore  in  this  neighborhood  may,  by  the  irritation  of  its  dis- 
charge, cause  tlieir  production.  They  owe  their  growth,  in  the  first 
place,  as  pointed  out  by  Diday,"  to  a  special  predisposition  to  the  forma- 
tion of  warty  growths  on  various  parts  of  the  body  in  the  individual,  and 
this  predisposition  is  assisted  by  the  presence  of  any  irritation  of  the 
part.  Thus  the  discharge  from  a  gonorrhoea  or  a  leucorrhoea,  or  any 
disease  of  the  rectum  or  genitals,  may  cause  them  to  grow,  and  they  may 
g,ppear  in  persons  apparently  perfectly  healthy  and  cleanly.  Pregnancy 
has  an  undoubted  influence  upon  their  production,  and  they  sometimes 
disappear  spontaneously  after  delivery.  From  what  has  been  said,  it  is 
evident  that  these  growths  are  neither  contagious  nor  inoculable,  and 
that  anti-syphilitic  treatment  can  be  of  no  avail. 

Symptoms. — These  vegetations  may  occur  at  any  age  from  infancy  to 
adult  life,  though  they  generally  belong  to  the  latter  period.  They  may 
vary  in  size  and  quantity  from  a  single  enlarged  papilla  at  the  verge  of  the 
anus  to  a  mass  such  as  is  represented  in  the  plate,  and  which  weighs 
as  much  as  a  pound.  The  symptoms,  in  any  case,  will  vary  with  their 
size,  number^  location,  and  the  amount  of  the  secretion.  When  they 
grow  from  one  side  of  the  intergluteal  fold,  and  are  large  enough  to 
press  with  their  moistened  surface  upon  the  corresponding  point  of  the 
opposite  side,  a  second  patch  may  be  developed  at  the  point  of  contact. 
The  irritation  from  any  other  source  would  have  the  same  effect.  The 
development  of  the  growths  may  be  slow  or  rapid,  and  when  the  tumors 

»  Op.  cit.,  p.  506. 

'Exposition    critique    et  pratique  des  nouvelles    doctrines  sur    la  syphilis. 
Paris,  1858. 


NON-MALIONANT   GEOWTH8   OF   THE    BECTUM    AND    ANC8.  145 

are  of  large  size,  the  patient  is  constantly  troubled  by  the  feeling  of  a 
foreign  body,  by  a  sanious  and  foul-smelling  discharge,  and  by  fresh 
erosions  and  8U})erficial  ulcers  in  the  adjacent  parts.  Great  pain  in  de- 
fecation may  bo  produced  by  a  small  wart  situated  just  at  the  verge  of 
the  anus,  and  such  a  little  tumor  may  give  rise  to  all  the  characteristic 
symptoms  of  a  painful  fissure,  including  a  slight  discharge,  and  an  oc- 
casional drop  or  two  of  blood.  They  are  not  very  infrequent  on  the  line  of 
junction  of  the  mucous  and  cutaneous  surfaces,  just  within  the  verge  of 
the  anus.  They  may,  also,  spring  entirely  from  the  mucous  membrane, 
above  the  sphincter,  though  they  are  generally  confined  to  the  first  inch 
of  the  canal,  and,  in  such  cases,  give  rise  to  a  much  more  aggravated  train 
of  symptoms,  and  to  much  difficulty  of  diagnosis.  There  they  are  gen- 
erally smaller  and  harder  than  when  on  the  cutaneous  surface,  and  cause  a 
serous  discharge,  which  may  be  so  profuse  as  to  escape  from  the  anus 
between  the  acts  of  defecation,  and  cause  much  suffering  from  pruritus 
and  rectal  tenesmus. 

On  examination  in  such  a  case,  the  mucous  membrane  will  be  found 
dry  and  glistening,  as  a  rule,  though  sometimes  there  may  be  a  more  or 
less  extensive  proctitis  ;  and  the  little  hard,  tender,  warty  excrescence, 
which  is  the  cause  of  all  the  grave  train  of  symptoms  and  of  so  much 
suffering,  may  easily  escape  detection.  The  only  treatment  for  such  a 
condition  is  to  seize  the  little  tumor  with  the  toothed  forceps,  and  excise 
the  mucous  membrane  to  which  it  is  attached.  It  may,  however,  return 
many  times. ' 

Diagnosis. — The  dignosis  of  these  growths  is  not  generally  difficult, 
tliough  care  is  necessary  when  they  are  small  and  located  within  the 
grasp  of  the  sphincters.  The  mistake  most  commonly  made  is  to  con- 
sider them  as  syphilitic  condylomata;  and,  indeed,  they  may  not  always 
be  easily  distinguishable  from  the  raised  mucous  patch  or  flat  condy- 
loma which  is  a  manifestation  of  true  syphilis.  A  careful  examination 
of  a  raised  mucous  patch  can  scarcely  fail,  however,  to  show  the  differ- 
ence between  its  general  character  and  that  of  a  cauliflower  growth 
which  has  sprung  up  from  the  surface  like  a  shrub,  and  is  attjvched  to  it 
by  numerous  little  pedicles.  The  two  may  exist  simultaneously,  the 
wart  being  caused  by  the  irritation  of  the  discharge  from  the  other. 
There  is  little  danger  of  mistaking  these  vegetations  for  malignant 
growths,  though  tliey  have  been  known  to  assume  a  semi-malignant  epi- 
thelial charactct',  and  to  return  frequently  after  removal. 

Treatment. — The  surest,  most  rapid,  and  in  every  way  most  satisfac- 
tory way  of  curing  these  vegetations,  is  by  simple  excision,  with  the 
knife  or  scissors.  The  ligature  is  often  inapplicable,  and  cauterization 
is  not  always  easy  to  limit  in  its  action.     The  growths  may,  however. 

'  Des  Vermes  de  rintestin  rectum.  Rognetta,  Gaz.  mM.  de  Paris,  June, 
1885. 

10 


146  DISEASES    OF    THE    RECTUM    AND    ANUS. 

often  be  induced  to  dry  and  shrink  up  by  applications  of  powdered  alum 
or  tannin,  and  by  washing  with  astringent  lotions,  such  as  Labaraque's 
solution. 

Condylomata. — The  term  condyloma  has  been  applied  to  many  differ- 
ent growths  around  the  anus,  as  well  as  to  the  raised  mucous  patch  al- 
ready spoken  of,  and  to  the  remains  of  external  haemorrhoids.  It  will  be 
used  here  to  refer  to  the  non-syphilitic  growths  of  skin  frequently  seen 
around  the  anus,  which  are  attached  by  a  broad  base,  are  pinkish  in 
color,  soft,  fleshy,  glistening,  moist,  and  irregular  in  shape,  flattened 
where  two  are  pressed  together,  or  where  one  is  subjected  to  the  pressure 
of  the  buttocks,  and  generally  giving  out  a  slight  secretion. 

They  generally  have  one  of  the  radiating  folds  of  the  anus  as  their 
point  of  departure,  and  they  differ  from  the  class  of  vegetations  last 
described,  in  that  they  consist  of  an  hypertophy  of  the  whole  thickness  of 
the  skin,  and  not  alone  of  the  papillae.  The  epithelial  element  in  them 
is  not  as  marked  as  in  the  warts,  and  the  blood-vessels  are  also  less 
developed.  They  are  merely  the  result  of  a  localized  chronic  inflamma- 
tion and  thickening  of  the  skin,  and  often  follow  an  external  haemor- 
rhoid  or  any  local  irritation  such  as  has  been  spoken  of  in  connection 
with  vegetations.  They  are  generally  isolated  and  few  in  number;  but 
it  may  happen  that  after  the  irritation  to  which  they  owe  their  origin 
has  ceased,  the  growth  may  continue,  becoming  harder  and  more 
movable,  and  resembling  a  ti'ue  fibroma.  Such  a  hard  tumor  may, 
under  sufficient  irritation,  take  on  an  ulcerative  and  suppurative  action, 
its  size  all  the  while  increasing,  until  a  foul,  painful,  indurated  mass 
results  which  strongly  resembles  malignant  disease.  Paget '  once  said 
that  without  considering  these  growths  as  absolutely  and  always  syphi- 
litic, they  are  so  rare  without  it,  that,  as  yet,  he  had  not  seen  a  case. 
They  are  a  very  common  accompaniment  of  any  ulcerative  process 
within  the  rectum,  and  hence  of  stricture,  and  many  a  stricture  has  been 
untruly  stamped  as  syphilitic  because  the  discharge  from  the  anus  had 
caused  a  development  of  these  fleshy  tags.  They  are  indeed  common  in 
syphilis  of  this  part,  but  they  are  not  syphilitic. 

These  condylomatous  tumors  occasionally  reach  a  large  size,  as  in  a 
case  recently  reported  by  Dr.  Barnes.^  The  tumor  in  his  case  was  the 
size  of  an  ordinary  orange,  and  had  been  protruded  from  the  anus  during 
labor.  It  proved  to  be  a  dense  growth  attached  to  the  margin  of  the 
anus,  the  rest  of  the  anal  circumference  being  surrounded  by  piles 
more  or  less  indurated.  At  one  point,  the  tumor  -was  greenish,  as  if 
about  to  sphacelate.  It  was  removed  by  galvano-cautery.  It  had  a  broad 
base,  and  Dr.  Barnes  looked  upon  it  as  an  outgrowth  from  a  hsemor- 
rhoidal  tumor.     Dr.  G-oodhart  reported  it  as,  for  the  most  part,  composed 

'  Med.  T.  and  Gaz.,  vol.  i..  1865,  p.  279. 
2 Br.  Med.  Jour.,  April  12th,  1879. 


NON-MALIGNANT   GROWTHS    OF   THE    RECTUM    AND    ANCS. 


147 


of  loose  fibro-cellular  tissue,  covered  by  a  tough  and  altered  mucous 
membrane;  the  deep  parts  were,  however,  cavernous  in  structure.  He 
was  of  /)pinion  that  it  originated  in  some  chronic  overgrowth  of  con- 
nective tissue  round  a  pile. 

The  diagnosis  of  these  growths  is  generally  easy.  They  can  scarcely 
be  mistaken  for  aught  except  a  syphilitic  gummy  deposit  or  malignant 
disease,  and  they  are  not  apt  to  be  confounded  with  either.  I  have  seen 
malignant  deposit,  however,  mistaken  for  simple  condyloma,  and  treated 
by  mercurials,  ablation,  and  the  hot  iron,  it  is  needless  to  say  without 
benefit. 

The  necessity  for  distinguishing  between  the  syphilitic  and  non- 
syphilitic  condylomata  around  the  anus  has  already  been  referred  to. 


Fxo.  47.— Condyloma  lata  or  vegetating  condyloma  (Bumstead  and  Taylor). 


There  is  a  variety  of  mucous  patch  situated  upon  the  skin  near  the  anus 
which  is  often  spoken  of  as  condyloma  lata  or  vegetating  condyloma. 

The  syphilitic  condyloma  first  manifests  itself  as  a  rod  spot  and  by  a 
slight  effusion  beneath  the  epidermis,  which  is  soon  rubbed  off  by  friction, 
exposing  a  raw  surface,  generally  covered  by  a  grayish  pellicle.  This  sur- 
face is  subsequently  elevated  by  an  upward  growth,  and  by  branching  of  the 
papillte,  with  formation  of  connective  tissue,  and  dilatation  of  the  blood- 
vessels. Where  this  development  of  the  papilla?  has  reached  a  consider- 
able extent,  the  cunlillower  appearance  is  the  result,  and  what  was  at 
first  a  simple  mucous  i)atch  may  become  a  large  pedunculated  wart 
surrounded  by  other  vegetations  which  have  sjirung  up  around  the 
original  lesion,  and  which  are  duo  to  the  irritation  of  its  presence 
(Bumstead  and  Taylor,  Keyes,  Biiumler). 


148  DISEASES   OF   THE    RECTUM    AND    ANUS. 

It  may  be  impossible  to  distinguish  this  form  of  syphilis  from  the 
simple  vegetation  already  described,  except  by  the  history,  the  fact  of  its 
infectiousness,  and  the  results  of  treatment.  Under  the  micvoscope, 
both  are  composed  of  an  hypertrophy  of  the  papillae  of  the  derma.  It 
ought  not,  however,  to  be  difl&cult  to  distinguish  between  this  syphilitic 
mucoas  patch  and  the  simple  hypertrophy  of  the  skin,  such  as  is  seen 
at  the  site  of  an  old  external  pile,  to  which  we  here  limit  the  name  of 
condyloma. 

This  loose  and  undefined  use  by  the  word  condyloma  is  much  to  be 
regretted,  but  is  so  common  as  to  make  any  change  out  of  the  question. 
It  is  used  here  to  denote  only  one  form  of  growth,  the  simple  non- 
syphilitic  hypertrophy  of  the  whole  skin.  What  is  usually  called  the 
syphilitic  condyloma  is  here  referred  to  as  the  raised  or  vegetating 
mucous  patch. 

The  only  treatment  necessary  in  cases  of  condylomata  is  their  simple 
excision,  after  Avhich  there  will  generally  be  no  return. 

Benign  fungus. — Under  this  title  Molliere'  describes  a  granular  condi- 
tion of  the  mucous  membrane  of  the  lower  end  of  the  rectum  occasionally 
£een  in  children  as  a  result  of  prolapse.  It  is  composed  of  soft,  friable, 
vascular  tissue  identical  with  the  granulations  of  a  cicatrizing  wound. 
The  surface  of  the  mass  is  red  and  uneven,  the  base  is  marked  by  dilated 
Teins.  After  defecation  the  tumor  may  remain  prolapsed,  but  it  is  easily 
reducible,  and  when  prolapsed  is  not  painful,  which  is  a  distinguishing 
mark  between  it  and  polypus.  The  haemorrhage  attending  this  form  of 
growth  is  always  abundant  and  may  cause  much  wasting.  On  account 
of  this  haemorrhage  the  growth  is  best  treated  by  cauterization  and 
astringents. 

Gummata. — These  also  may  affect  either  anus  or  rectum,  though  their 
rarity  in  the  latter  may  best  be  judged  by  the  statement  of  Fournier*  that 
he  has  never  seen  one,  and  only  admits  their  existence  on  the  testimony 
of  Verneuil  who  has  seen  one.  However,  their  presence,  a  fortiori  prob- 
able, has  been  demonstrated  by  other  observers  than  Verneuil.  Esmarch' 
admits  it;  Zeissl*  reports  a  case  in  a  male,  and  Zapjiula*  another; 
Molli^re'  has  seen  one  starting  at  the  anus  and  extending  into  the  ischio- 
rectal fossa;  and  Fournier'  himself  met  one  in  a  young  woman  starting 
in  the  left  buttock  and  secondarily  involving  the  anus  and  then  the  rec- 
tum. 


>  Op.  cit.,  p.  524. 

*  Lesions  tertiaires  de  I'Anus  et  du  Rectum,  Paris,  1875,  p.  8. 

«0p.  cit. 

<  Vrtljschr.  f.  Dermatol,  u.  Syph,,  1876,  H.  ii. 

"Ann.  Univ.  de  Med.,  Milan,  ccxiii.,  1870. 

« Op.  cit.,  p.  645. 

'  Op.  cit. 


NON-MAUONANT   GROWTHS   OF   THE   RECTUM    AND   ANUS.  149 

Ano-rectal  syphiloma. — This  affection  is  defined  by  Fournier'  as  "an 
infiltration  of  the  rectal  walls  by  a  neoplasm,  whose  initial  structure  is  still 
undetermined,  but  susceptible  of  degenerating  into  retractile  fibrous 
tissue  and  of  constituting  in  this  way  more  or  less  extensive  intes- 
tinal strictures."  He  speaks  of  its  also  as  "hyperplastic  rectitis 
becoming  later  a  fibro-sclerous  rectitis,"  and  as  identical  or  at  least 
analogous  to  other  lesions  of  the  same  order  developed  in  different 
viscera,  as  the  liver  or  testicle.  He  particularly  emphasizes  the  fact 
that  this  process  begins  in  the  submucous  layers,  and  that  the  mu- 
cous membrane  is  only  secondarily  destroyed,  being  at  first  entirely  free 
from  ulceration  or  cicatrices.  Its  point  of  predilection  is  the  rectal 
pouch,  but  it  may  be  found  below.  He  has  never  seen  it  above.  Some- 
times only  two  or  three  centimetres  of  the  wall  are  involved,  but  when  it 
begins  at  the  anus  it  may  reach  seven  or  eight  centimetres  up.  It  forms 
a  cylinder  around  the  whole  circumference  of  the  bowel.  In  the  initial 
stage  the  rectum  is  only  stiffened  and  thickened  but  not  contracted. 
Wiieu  the  infiltration  is  limited  to  the  vicinity  of  the  anus,  it  is  not  uni- 
formly diffused  around  its  circumference,  but  forms  irregular  masses 
which  are  at  first  covered  by  healthy  tissue.  These  are  painless  unless 
inflamed,  but  are  liable  to  erosion  and  ulceration.  The  disease  is  more 
common  in  females  than  in  males — eight  to  one. 

Unfortunately  the  specific  character  of  this  ulceration  cannot  be 
proved  under  the  microscope,  there  being  nothing  distinctive  in  its  struc- 
ture. The  theory  advanced  by  Fournier  has  held  its  own,  however,  and 
has  gained  adherents.  Duplay*  adopts  it,  and  Van  Buren  has  distinctly 
recognized  this  form  of  disease,  and  has  also  "  seen  it  disappear  under 
anti-syphilitic  treatment,"  though  Fournier  says  distinctly  the  anti- 
syphilitic  treatment  exercises  no  curative  influence  on  confirmed  syphi- 
litic retraction,  and  this  he  explains  on  the  ground  that  the  contraction 
is  less  a  syphilitic  lesion  than  the  ultimate  consequence  of  a  syphilitic 
lesion,  just  as  a  cicatrix  is  the  ultimate  consequence  of  a  wound. 

The  remaining  tumors  which  occur  in  tliis  part  of  the  body  are  very 
rare,  so  rare  as  to  be  rather  curiosities  than  otherwise;  and  yet,  as  they 
may  be  met  with  at  any  time,  it  will  not  be  a  waste  of  time  to  enumerate 
them  and  say  a  few  words  concerning  each  in  turn. 

Fibromata. — True  fibrous  tumors  may  develop  outside  of  the  anus. 
Curling*  gives  a  description  of  one  such  case  removed  by  Mr.  Hovel,  of 
Clapton,  which  had  been  growing  for  seven  years  and  weighed  upwards 
of  half  a  pound.  It  was  composed  of  fibrous  tissue  arninged  in  several 
k)bos,  was  pendulous  and  attached  to  the  margin  of  the  anus  by  a  narrow 
neck.     The  surface  was  ulcerated  from  friction.     He  remarks  that  they 


'  Lesions  Tertiaires  de  TAnus  et  du  Rectum,  Paris,  1875. 
'  Le  Progres  Med.,  Nov.  80th,  1876. 
»0p.  cit.,  p.  188. 


150  DISEASES    OF   THE    EECTUM    AND    ANUS. 

seldom  exceed  the  size  of  a  chestnut,  and  that  their  surface  is  generally 
irregularly  lobulated. 

Lipomata. — Of  these  fatty  tumors  there  are  only  a  few  scattered  cases 
in  literature  from  which  to  derive  a  general  knowledge  of  their  character- 
istics in  this  part  of  the  body.  Esmarch'  speaks  of  two  cases,  one  observed 
by  Weiss,  the  other  by  Bose.  The  former  occurred  in  the  surgical  clinic 
at  Prag,  its  size  was  that  of  a  plum,  and  it  had  caused  an  invagination  of 
the  sigmoid  flexure  into  the  rectum  and  a  prolapse  nearly  four  inches  in 
length.  After  extirpation  of  the  tumor  and  ligature  of  the  pedicle,  the 
prolapse  was  reduced  and  the  invagination  overcome  by  forced  injections. 
The  second  case  was  somewhat  similar  and  occurred  in  Langenbeck's  cli- 
nic. Molliere"  gives  two  cases  in  full.  One  from  CI.  Bernard^  in  a 
woman  eighty-three  years  of  age,  who  complained  of  obstinate  constipation 
and  dyspepsia,  and  a  sensation  as  if  of  the  weight  of  a  foreign  body  in 
the  rectum.  By  making  a  digital  examination  upon  herself  she  could  feel 
the  tumor,  and  she  soon  succeeded  in  evacuating  it.  It  weighed  twenty 
grammes,  was  about  the  size  of  a  pigeon's  egg,  was  composed  entirely  of 
fat,  and  had  a  distinct  and  slender  pedicle.  The  other  case,*  reported  by 
Castilain,  occurred  in  a  man  aged  forty-three,  wlio  complained  of  the 
same  symptoms  of  constipation  and  dyspepsia,  and  this  also  was  expelled 
spontaneously  by  the  straining  of  the  patient.  The  doctor  at  first  sup- 
posed the  mass  to  be  a  ball  of  hardened  faeces,  but  a  closer  examination 
proved  it  to  be  an  ovoidal  tumor  measuring  twelve  centimetres  in  length 
by  six  in  thickness.  The  consistence  was  firm,  and  the  section  reddish 
in  color  The  tumor  showed  numerous  lobules  and  was  enveloped  in  a  re- 
sisting envelope.  At  one  end  there  was  a  distinct  pedicle  two  or  three 
centimetres  long,  and  slender.  Spencer  Wells*  has  also  reported  a  large 
lobulated  fatty  tumor  weighing  two  pounds  which  he  removed  from  the 
recto-vaginal  septum. 

Fatty  tumors  may  also  occur  in  the  region  around  the  anus  and  en- 
croach upon  it  to  a  greater  or  less  extent.  Molk'  in  his  well-known  thesis 
gives  several  such  examples.  They  may  be  divided  into  the  pedunculated 
and  non-pedunculated.  The  former  occur  especially  in  children,  and  are 
easily  removed  by  knife,  scissors,  or  galvano-cautery  wire,  and  generally 
without  great  danger.  The  non-pedunculated  variety  is  much  rarer. 
Molk  relates  one,  in  a  still-born  child,  which  filled  the  pelvis,  and  de- 


•Op.  cit.,  p.  154. 

-  Op.  cit.,  p.  525  et  seq. 

^  Azefou,  Bull,  de  la  Soc.  anatomique,  seance  du  Mars  26,  1875. 

••Gaz.  hebdomadalre,  Mai,  1870,  p.  318,  et  Bull.  Med.  du  Nord  de  la  France, 
Mars,  1870. 

■Trans.  London  Path.  Soc,  vol.  xvi,,  p.  277. 

*  Des  tumeurs  congenitales  de  Textremite  inferieur  du  tronc.  These  de  Stras- 
bourg, 1868,  No.  106. 


NON-MALIGNANT    GROWTHS    OF   THE   EECTUM    AND    ANUS.  151 

scended  to  the  calves  of  the  legs.  Robert'  has  recorded  another  in  which 
the  tumor  si)r:ing  from  the  ischio-rectal  fossa  and  was  at  fitst  mistaken 
for  a  perineal  hernia.  It  occurred  in  a  riding  master,  forty-five  years  of 
age,  and  measured  ten  centimetres  by  seven.  The  operation  at  first  con- 
sisted in  cutting  down  upon  the  tumor  layer  by  layer  as  in  the  case  of  a 
hernia,  but  as  soon  as  its  true  nature  was  evident  it  was  followed  into  the 
ischio-rectal  fossa  and  extirpated.     The  patient  was  well  in  a  fortnight. 

Virchow*  has  made  a  study  of  these  intestinal  fatty  tumors  from  which 
the  following  general  facts  may  be  derived.  The  fatty  tissue  of  which 
tiiey  are  composed  is  apt  to  undergo  inflammatory  changes  by  which  the 
general  appearance  of  the  tumor  is  changed,  so  that  when  it  appears  at 
the  anus  it  may  seem  like  a  hard  fleshy  tumor  of  dark-red  color  on  sec- 
tion. Another  result  of  the  irritation  to  which  they  are  exposed  is  the 
formation  of  a  hard  crust  on  their  surface  which  may  finally  become  car- 
tilaginous and  cause  them  to  be  confounded  with  faecal  calculi.  Instead 
of  an  inflammatory  hardening,  a  central  softening  may  occur,  and  a 
cavity  be  formed  containing  free  liquid  fat.  Cretaceous  masses  may  also 
be  found  in  the  centre  of  the  tumors. 

In  general,  these  tumors  are  attached  high  up  the  bowel,  and  hence 
the  pedicle  may  contain  peritoneum.  They  are  very  apt  to  cause  invagi- 
nation, as  in  Esmarch's  case,  and  this  coincidence  should  always  be  borne 
in  mind  when  one  is  found  presenting  at  the  anus. 

Enchondroma. — Cartilaginous  tumors  of  the  rectum  proper  are  of 
exceeding  rarity,  and  when  found  they  are  generally  the  result  of  a 
secondary  change  in  a  tumor  primarily  glandular,  and  do  not  therefore 
present  the  well-known  characteristics  of  the  typical  enchondroma. 
M.  Dolbeau  has  reported  *  a  case  of  encliondroma  of  the  lower  part  of  the 
rectum,  removed  from  a  young  man  aged  twenty-seven.  The  tumor  was 
the  size  of  a  hazel-nut,  was  hard  and  movable,  and  located  at  the 
entrance  of  the  anus,  where  it  caused,  no  pain  except  when  a  sound  or 
syringe  was  used.  Around  the  tumor,  the  mucous  membrane  was  eroded. 
The  microscopic  examination  showed  a  predominance  of  the  fibro-carti- 
laginous  element  with  glandular  culs-de-sac,  in  the  proportion  of  one  to 
four.  M.  Dolbeau  did  not  believe  that  the  tumor  was  developed  from 
tlio  glands  of  the  rectum,  and  Robin  thought  that  the  glandular  elements 
of  the  tumor  were  of  new  formation. 

Cysts. — Cysts  in  the  neighborhood  of  the  rectum  and  anus  may  be  of 
many  varieties.  Of  the  dermoid,  there  are  several  recorded  examples. 
At  a  meeting  of  the  London  Pathological  Society,  May  18th,  1880,  Dr. 
Port*  showed  a  tumor  he  had  removed  from  the  rectum  of  a  girl  aged 

'  Lipome  de  I'anus  simulant  une  hemie  perineale.  Annales  de  therapteutique, 
Oct..  1844. 

'  Patliologie  des  Tumeurs.  Translation  par  Aronasohn,  voL  L,  Chap.  14. 
'  Bull,  de  la  Soc.  Anat..  sf»cond  series,  t.  v.,  p.  6. 
*  Brit.  Med.  Jour..  May  29th.  ISSO.  p.  811. 


152  DISEASES   OF   THE   RECTUM    AXD    ANUS. 

sixteen.  It  was  mainly  composed  of  fibrous  tissue  inclosed  in  an  integu- 
ment like  ordinary  skin,  covered  with  long  hair,  and  containing  abundant 
involuntary  fibre  like  that  seen  in  the  normal  cutis.  Growing  upon  it 
also  was  a  well-developed  canine  tooth.  The  author  refers  to  a  somewhat 
similar  case,  recently  reported  in  Germany,  in  which  the  tumor  contained 
not  only  a  tooth  but  brain  substance. 

Danzell '  reports  a  case  in  a  woman,  aged  twenty-five  years,  in  whom 
a  lock  of  brown  hair,  the  size  of  the  finger,  protruded  from  the  anus 
occasionally  after  defecation.  In  the  front  wall  of  the  rectum,  about  two 
and  a  half  inches  from  the  anus,  a  hard  tumor  could  be  felt  about  the 
size  of  a  small  apple.  This  was  extirpated  by  introducing  the  whole  hand 
into  the  rectum  after  Simon's  method,  death  following  some  months 
after  from  localized  peritonitis. 

The  hair  growing  from  this  tumor  was  from  twelve  to  eighteen  centi- 
metres long.  The  tumor  itself,  when  extirpated,  measured  4.5  cm.  in 
length,  4  cm.  in  breadth,  and  3.5  cm.  in  thickness,  and  the  microscopic 
examination  showed  the  usual  cyst-wall  and  contents. 

Perrin  ^  gives  an  account  of  three  cases  of  these  tumors,  which  may  be 
briefly  extracted. 

Case  XIV. — Woman,  aged  thirty  years.  First  noticed  small  tumor  at 
point  of  coccyx  a  few  months  after  confinement.  Tumor  round,  elastic, 
well  defined,  firmly  adherent  to  point  of  coccyx,  painless  to  the  touch, 
but  more  sensitive  at  menstrual  epochs,  and  when  the  patient  was  in 
sitting  posture.  At  this  time  it  was  the  size  of  a  small  nut,  but  a  year 
later  it  had  increased  considerably,  and  extended  from  the  anus  to  the 
sacrum;  it  gave  a  sense  of  fluctuation  to  the  touch,  and  was  unattached 
to  the  skin.  Defecation  painful.  The  sac  of  the  tumor  was  extirpated 
after  its  steatomatous  contents  were  emptied  without  difficulty.  It  was 
adherent  by  fibrous  tissue  to  the  point  of  the  coccyx,  but  not  elsewhere. 
The  examination  after  removal  showed  it  to  be  about  the  size  of  a  hen's 
egg,  with  the  large  extremity  turned  toward  the  anus.  It  was  composed 
of  an  envelope  and  contents.  The  envelope  was  composed  of  two  distinct 
layers;  the  outer,  fibrous  and  elastic,  and  showing  the  elements  of  cellu- 
lar tissue  under  the  microscope;  the  inner,  thin,  transparent,  and 
resembling  a  very  thin  layer  of  cartilage.  Under  the  microscope  this 
transparent  layer  was  composed  of  flattened,  transparent,  polygonal  epi- 
thelial cells  about  one-fortieth  mm.  in  diameter. 

The  contents  of  the  sac  consisted  of  whitish  matter,  disposed  in  layers 
at  the  circumference,  but  mingled  in  a  tallowy  mass  in  the  centre;  seen 
under  the  microscope  to  be  composed  of  epithelial  cells  filled  with  fatty 
matter.     Cure. 


'  Geschwulst  mit  Haaren  im  Rectum.     Arch,  fur  Clin.  Chirurg.,  1874,  p.  44? 
^  De  la  Glande  coccygienne  et  des  tumeurs  dont  elle  peut  etre  le  siege.     Stras- 
bourg, 1860,  These  No.  536. 


NON-MALIONANT   OROWTH8   OF   THE   RECTCM    AND    ANC8.  153 

Case  XV. — "Woman,  aged  twenty-seven  years.  This  tumor  had  been 
growing  for  five  years.  It  first  appeared  as  a  small  tubercle  about  one- 
third  of  an  inch  in  size,  very  hard  and  painless,  at  the  left  side  of  the 
coccyx.  For  the  first  three  years  it  wjis  painless,  but  during  the  latter 
two  had  caused  more  uneasiness  when  struck  or  pressed  upon.  After  a 
time  the  pain  was  increased,  and  became  continuous  with  remissions  and 
exacerbations,  and  the  size  began  to  increase,  while  the  surrounding  parts 
took  on  an  inflammatory  action.  The  pain  followed  the  course  of  the 
sciatic  nerve  on  the  side  of  the  tumor,  and  after  a  while  it  became  impos- 
sible to  lie  on  the  back  or  to  walk.  At  this  time  the  tumor  had  increased 
to  the  size  of  a  child's  fist,  and  rested  on  the  left  sacro-sciatic  ligament. 
The  skin  and  subcutaneous  tissue  over  it  were  healthy  and  not  adherent. 
The  tumor  itself  was  hard  and  somewhat  elastic,  and  adherent  to  the 
subjacent  parts. 

The  tumor  having  been  completely  separated  by  enucleation  and  dis- 
section from  surrounding  parts,  was  cut  away  with  curved  scissors,  care 
being  taken  to  cut  the  osseous  portion  as  much  as  possible  in  a  longitudi- 
nal direction.  The  excised  portion  presented  a  fibrous  shell,  like  that  of 
a  cyst,  containing  in  its  upper  part  a  caseous,  grayish  substance  which 
increased  in  consistence  in  proportion  as  it  neared  the  base,  where  it  was 
of  fibrous  hardness  and  appearance,  then  became  fibro-cartilaginous,  and, 
at  the  base,  where  it  was  adherent  to  the  bony  outgrowth  from  the  coc- 
cyx, it  was  almost  cartilaginous.  The  interior  of  the  tumor  was  perfo- 
rated with  spaces  inclosing  a  liquid  matter  resembling  pus.     Cure. 

Case  XV I. — Man,  aged  twenty-four  years.  Fibrous  cyst,  size  of  a 
pigeon's  egg,  filled  with  liquid  contents.     Cure. 

Molliere  also  reports  one  case  of  his  own,  in  a  young  girl  in  whom  the 
tumor,  the  size  of  a  small  almond,  was  covered  by  healthy  skin. 

From  these  cases,  the  general  characters  of  these  tumors  may  be 
deduced.  The  are  generally  soft,  pasty,  and  indolent,  covered  by  healthy 
skin,  to  which  they  are  not  adherent,  and  firmly  attached  to  the  sacrum 
or  coccyx.  They  occur  most  frequently  in  adults,  and  seldom  attain  any 
size  larger  than  that  of  a  hen's  egg.  They  grow  slowly  for  a  longer  or 
shorter  time,  until  an  inflammatory  action  is  excited,  when  acute  symp- 
toms supervene,  and  they  demand  attention.  They  may  contain  seba- 
ceous matter,  hair,  or  teeth,  and  may  be  located  either  within  the  rectum, 
which  is  very  rare,  or  in  the  ano-coccygeal  region,  which  is  more 
common. 

While  s}>eaking  of  tumors  containing  hair,  etc.,  it  may  be  well  to 
refer  to  an  affection  which  Dr.  Hodges,'  of  Boston,  has  described  under 
the  name  of  **  pilo-iiidal  sinus"  (pilus,  a  liair;  nidus,  a  nest),  and  which 
has  for  some  time  been  known  in  French  literature  by  the  name  of  the 
posterior  umbilicus.     The  affection  is  simply  a  ball  of  hair  and  dirt  in  a 


Bostou  Med.  and  Surg.  Journal,  Nov.  IStli,  1880. 


154  DISEASES    OF    THE    RECTUM    AND    ANUS. 

sinus  between  the  anus  and  the  tip  of  the  coccyx.  The  sinus  is  a  deep, 
symmetrical,  somewhat  conical  dimple  of  congenital  origin,  representing 
an  imperfect  union  of  the  lateral  halves  of  the  body,  involving  the 
integument  alone,  in  which,  as  life  advances,  short  hairs  and  other 
particles  accumulate.  These,  by  their  irritation,  cause  a  purulent  dis- 
charge from  the  fistulous  opening  of  the  cavity,  and  when  the  case  comes 
under  the  observation  of  the  surgeon,  it  is  usually  mistaken  for  fistula- 
in-ano.     The  hair  being  removed,  the  sinus  closes  by  granulation. 

This  sinus  is  never  found  in  children,  never  in  men  who  do  not  have 
a  large  amount  of  hair  about  the  nates,  and  so  rarely  in  women  that  the 
records  of  the  Massachusetts  General  Hospital  include  but  a  single 
instance,  and  in  this  patient  there  was,  for  a  female,  an  unusual  gi-owth 
of  hair.  For  the  development  of  the  affection,  there  are  necessary  a  con- 
genital coccygeal  dimple,  an  abundant  pilous  growth  (hence  adult  age, 
'  and  almost  of  necessity  the  male  sex),  and  insufficient  attention  to 
oleanliness.  The  affection  is,  therefore,  met  with  in  persons  of  the  lower 
class,  and  in  hospital,  rather  than  private  practice. 

Hydatids. — The  number  of  hydatid  cysts  of  the  pelvis  which  have 
been  reported  is  by  no  means  inconsiderable.  F.  Villard  '  has  collected 
thirteen  of  them  in  women,  and  the  standard  surgical  writers  mention 
their  occasional  occurrence.  Bryant  mentions  removing  a  "  basinful " 
of  secondary  cysts  from  one  in  this  position.  These  swellings  are  to  be 
recognized  by  their  tense,  globular,  and  elastic  feel,  and  by  the  fact  of 
their  causing  no  symptoms  except  those  due  to  pressure,  except  in  cases 
of  suppuration  after  the  death  of  the  entozoon.  The  cyst  has  laminated 
walls  lined  with  a  granular  layer,  and  is  usually  surrounded  by  a  con- 
nective tissue  capsule  formed  from  the  part  in  which  it  is  imbedded.  It 
may  be  of  any  size,  and  contains  a  clear,  watery,  albuminous  fluid,  in 
which  may  be  found  parts  of  the  entozoon. 

Fatal  Inclusions. — In  these  congenital  cysts,  any  foetal  structure  may 
be  found.  They  are  not  so  rare  but  that  several  very  complete  studies 
have  been  made  of  them.  Molk*  gives  numerous  examples;  Verneuil ' 
has  collected  ten  cases;  and  Paul  *  has  Avritten  exhaustively  on  the  sub- 
ject, his  article  being  founded  on  a  study  of  twenty-eight  cases.  That 
variety  which  is  located  in  the  sacro-perineal  region  is  the  most  fre- 
quent of  all.  The  sac  is  composed  of  three  layers,  cutaneous,  fibrous, 
and  serous.  The  skin  is  thinned  from  distention,  is  violet  or  bluish  in 
color  from  congestion,  and  an  inflammation  or  a  spontaneous  rupture  may 
cause  perforation  of  the  sac,  and  the  escape  of  the  fluid  contents.     The 

'  Considerations  cliniques  sur  les  Kystes  hydatiques  du  petit  bassin  chez  la 
femme.     Annales  de  Gynecologie,  1878,  p.  101. 
'  Surgery,  p.  152,  Anier.  ed. 

*  Arch.  Gen.  de  Med.,  1855. 

*  Etude  pour  servir  a  Thistoire  des  monstrosites  parasitaires  de  Tinclusion  foetal' 
situe  dans  la  region  sacro-perineale.     Arch.  Genl.  de  Med.,  t.  xx.,  1862. 


NON-MAUONANT   OEOWTH8   OF  THE   RBOTUIC  AND   ANUS.  166 

fibrous  layer  may  be  more  or  less  resistant.  It  is  sometimes  composed  of 
a  simple  hypertrophy  of  connective  tissue,  at  others,  it  is  aponeurotic  in 
character.  When  the  sac  communicates  with  the  spinal  canal,  this 
fibrous  layer  is  a  direct  extension  of  the  dura  mater  of  the  cord.  The 
serous  layer  is  smooth,  and  covered  by  pavement  epithelium,  and  to  one 
side  of  it  the  included  foetus  will  be  found  attached.  This  may  also  be  a 
continuation  of  the  arachnoid  of  the  cord. 

These  cysts  contain  a  serous  fluid  and  foetal  contents  in  the  form  of 
an  irrgular  mass,  hard  and  soft  m  spots.  Any  and  every  part  of  a  foetus 
may  be  discovered  in  this  mass.  The  tumor  is  ovoidal  in  shape, 
resembling  an  egg  when  small,  or  the  scrotum  when  larger.  The  size  is 
generally  equal  to  that  of  the  head  of  the  foetus  which  bears  it,  but  some- 
times equals  that  of  the  head  at  term,  and  may  be  larger.  The  tumor 
may  be  bilocular,  its  contents  generally  give  fluctuation,  and  are  irre- 
ducible except  where  there  is  a  communication  with  the  spinal  canal. 
There  is  no  pain  unless  inflammation  has  supervened.  The  diagnosis  is 
generally  made  by  discovering  a  hard  mass  of  foetal  elements  in  the 
midst  of  a  serous  cyst.  When  the  cyst  communicates  with  the  spinal 
canal,  the  differential  diagnosis  between  it  and  a  spina  bifida  may  be 
impossible. 

Such  a  cyst  may  cause  death  by  obstructing  labor,  or  by  the  develop- 
ment of  a  gangrenous  inflammation  after  birth.  As  a  rule,  operations 
for  their  removal  have  not  resulted  successfully  when  undertaken  during 
the  first  three  years  of  life.  One  operation  practised  at  a  later  date  has, 
however,  been  crowned  with  success. 

Spina  Bifida. — Concerning  this  variety  of  cyst  little  need  be  said  ex- 
cept as  regards  its  diagnosis.  It  should  be  borne  in  mind  that  a  tumor 
due  to  a  deficiency  of  the  spinal  bones  may  be  entirely  within  the  |)elvis, 
in  which  case  it  would  present  great  difficulties  in  diagnosis.  Such  a  case 
is  the  following.' 

Case  XVII. — Woman,  aged  36,  single.  The  patient  stated  that  ten 
years  before,  she  detected  a  swelling  as  large  as  a  goose  egg  in  the  right 
iliac  region,  her  attention  having  been  called  to  it  by  shooting  pains 
through  the  abdomen  starting  from  this  point.  The  size  of  the  tumor 
increased  slowly,  had  once  caused  retention  of  urine,  and  now  caused 
oedema  of  the  right  leg.     The  patient  was  cachetic  and  emaciated.  .  .  . 

The  abdomen  was  uniformly  enlarged  and  tympanitic.  On  making 
a  vaginal  examination,  the  cervix  uteri  could  be  scarcely  reached,  situated 
as  it  was  above  the  pubes,  while  a  mass  was  felt  behind  in  the  cul-de-sac, 
extending  to  the  right,  apparently  an  ovarian  cyst.  But  from  a  digital 
examination  in  the  rectum  it  was  evident  that  the  rectum  was  pushed 
forward  by  a  large,  soft,  fluctuating  tumor  behind  it,  which  filled  up  the 
hollow  of  the  sacrum  to  within  a  short  distance  of  the  anus.  .  .  . 

'  Emmet:  Prin.  and  Prac.  of  GyMecology,  Ist  ed.,  p.  773. 


156  DISEASES    OF   THE   KECTUM    AND    ANUS. 

The  patient  was  placed  under  ether,  and  a  fine  trocar  was  introduced 
into  the  sac,  about  three  inches  beyond  the  anus,  by  which  an  ounce  or 
mor^of  its  contents  were  aspirated  by  Dieulafoy's  pump.  This  fluid  was 
serous  in  character,  perfectly  clear  and  limpid,  resembling  hysterical 
urine.  It  contained  no  albumen,  and  the  microscope  revealed  nothing 
more  than  a  few  oil  globules,  which  had,  beyond  question,  been  attached 
to  the  instrument  before  its  introduction. 

Autopsy  nine  and  a  half  hours  after  death.  On  opening  the  abdomen, 
the  colon  was  so  much  distended  as  to  fill  the  whole  cavity,  and  reached 
to  a  level  of  the  fourth  rib,  being  filled  with  flatus  and  faeces.  ...  A. 
cyst  which  contained  some  three  quarts  of  fluid  was  found  behind  and 
to  the  right  of  the  rectum,  filling  completely  the  cavity  of  the  pelvis,  and 
extending  up  to  a  line  with  the  second  lumbar  vertebra.  .  .  .  The 
rectum  was  greatly  constricted  in  its  upper  portion ....  In  attempt- 
ing to  discover  the  attachments  of  the  cyst  m  the  hollow  of  the  sacrum. 
it  was  ruptured.  The  sacrum  was  removed,  and  a  spina  bifida  found, 
the  three  lower  bones  of  the  sacrum  being  deficient  on  the  right  side.  A 
funnel-shaped  opening  communicated  directly  with  the  spinal  canal,  from 
which  projected  portions  of  the  cauda  equina  an  inch  or  more  in  length. 
.  .  .  Although  the  posterior  portion  of  the  bones  were  wanting,  no 
external  bulging  of  the  sac  could  take  place  posteriorly  in  consequence  of 
the  dense  ligamentous  structures  bridging  it  over. 

The  diagnosis  of  spina  bifida  can  generally  be  made  by  the  reduci- 
bility  of  the  tumor,  the  signs  of  pressure  on  the  brain  and  spinal  cord 
which  are  produced  by  pressure  on  the  tumor,  the  fluctuation  at  the  fon- 
tanelles,  and  the  chemical  character  of  the  fluid  which  may  be  withdrawn 
for  the  purpose  of  diagnosis.  The  fluid  of  a  spina  bifida  contains  both 
sugar  and  urea  as  does  that  of  the  cerebro-spinal  canal,  and  though  both 
these  substances  may  be  found  in  cysts  entirely  independent  of  the  cere- 
bro-spinal canal,  they  will  always  be  found  in  spina  bifida. 

There  still  remains  a  class  of  congenital  cysts  which  are  neither  con- 
nected with  the  spinal  canal  (spina  bifida),  nor  parasitical  (containing 
fcetal  remains).  These  are  often  of  large  size  at  the  time  of  birth,  and 
may  consist  of  a  single  cyst  or  be  multilocular.  They  are  generally 
attached  by  a  pedicle  near  the  tip  of  the  coccyx,  though  the  cyst  or  cysts 
may  have  prolongations  in  the  perineum  or  the  ischio-rectal  fossae.  The 
cyst-wall  in  these  cases  is  fibrous,  and  when  many  cysts  are  present  it 
sends  prolongations  between  them.  The  integument  covering  it  is  thin 
and  generally  marked  by  large  veins.  The  cyst  is  filled  with  a  yellowish, 
tenacious,  gelatinous  fluid,  transpai*ent  to  light  as  is  a  hydrocele.  It 
will  be  seen  at  once  that  the  great  difl&culty  in  diagnosis  lies  between  this 
form  of  cyst  and  a  spnia  bifida,  and  though  the  diagnosis  may  not  always 
be  possible,  it  will  generally  turn  upon  the  presence  or  absence  of  the 
signs  of  communication  with  the  spinal  canal  when  pressure  is  made  upon 
the  tumor. 


NON-MALIGNANT   OBOWTHS   OF  THE    RECTUM    AND    ANUS.  157 

The  treatment  of  these  growths  is  by  extirpation.  Injections  of 
iodine,  etc.,  have  in  them  the  element  of  danger  from  prolonged  and  ex- 
tensive suppuration.  When  extirpation  is  attempted  it  should  be  com- 
plete; and  where  the  cyst  is  multilocular  it  should  be  followed  into  the 
perineum  and  ischio-rectal  fossae  if  necessary,  in  order  that  no  parts  of  it 
may  remain  to  undergo  subsequent  development.*  These  cystic  forma- 
tions, unless  of  sufficient  size  to  cause  death  during  labor,  are  not  incom- 
patible with  life. 

I  Buneau:  Bull,  de  la  See.  M6d.  de  la  Suisse  roniande  (MoUiSre). 


158  DISEASES   OF   THE   BECTUM   AND    ANUS. 


CHAPTER   IX. 

NON-MALIGNANT    ULCERATION.' 

Varieties. — Simple  Ulcers. — Grenerally  due  to  Traumatism. — Various  Forms  of  In- 
jury to  which  Ilectum  is  Subject. — Sodomy. — Injury  of  Rectum  in  Labor. — 
Ulcers  due  to  Surgical  Interference. — Fissure  or  Irritable  Ulcer. — Nothing 
Distinctive  in  the  Ulcerative  Process. — Characteristics  pf  Irritable  Ulcer. — 
Theories  concerning  this  Form  of  Ulcer. — Description. — Herpes. — Tubercular 
Ulceration. — Distinction  between  True  Tubercular  Ulcer  and  a  Simple  Ulcer 
in  a  Tuberculous  Person. — Description  of  Each — Scrofulous  Ulceration. — 
Esthiomene. — Rodent  Ulcer. — Dysentery. — A  Cause  of  Stricture. — Venereal 
Ulceration. — Gonorrhoea. — Chancroids. — Chancroidal  Stricture. — Discussion. 
— True  Chancre. — Secondary  and  Tertiary  Syphilitic  Ulcerations. — Diagnosis 
of  Syphilitic  Ulcers. — Ano-rectal  Syphiloma  as  a  Cause  of  Ulceration. — Ulcera- 
tion Secondary  to  Stricture. — Gangrene. — Symptoms  of  Ulceration. — Gravity 
of  the  Disease. — Diagnosis. — Treatment. — General  and  Local  Measures. — 
Treatment  of  Fissure. — Fissure  Complicated  with  Polypus. — Treatment  by 
Rest,  Fluid  Diet  and  Incision  of  the  Sphincter. — Local  Applications. 

The  many  different  varieties  of  non-malignant  ulcers  which  are  met 
with  at  the  anus  and  within  the  rectum  may  best  be  classified,  from  the 
stand-point  of  etiology,  into  the  following  groups:  1.  Simple.  2.  Tuber- 
cular. 3.  Scrofulous.  4.  Dysenteric.  5.  Venereal.  6.  Those  due  to 
stricture.     7.  Those  due  to  gangrene  around  the  rectum. 

Simple  Ulcers. — These  are  almost  always  of  traumatic  origin,  and  the 
most  frequent  traumatism  to  which  the  rectum  is  subject  is,  perhaps, 
that  arising  from  the  presence  and  passage  of  hardened  faeces.  From 
this  cause  alone,  or  from  this,  combined  with  their  extrusion  from  th& 
anus,  the  surface  of  projecting  liEemorrhoidal  tumors  may  become 
ulcerated  for  a  considerable  extent ;  and,  by  this  means,  a  fissure  is  often 
produced  within  the  grasp  of  the  sphincter.  The  latter  I  have  known  to 
happen  on  the  first  evacuation  of  the  bowels  after  an  operation  for 
haemorrhoids  (the  bowels  having  been  confined  by  medicine  for  several 
days),  rendering  necessary  the  usual  operation  for  its  cure  at  a  subsequent 
time.     Another  frequent  cause  of  direct  injury  is  the  presence  of  foreign 

'  A  part  of  this  chapter  and  of  the  following  one,  on  cancer,  originally  appeared 
inthe  American  Journal  of  the  Medical  Sciences.  Oct.,  1880;  April,  1881. — Author. 


NON-MALIGNANT    LLCKBATluN. 


159 


bodies,  either  fish-bones,  date-stones,  etc.,  which  have  been  swallowed,  or 
lai'ger  substances  which  have  been  intentionally  introduced  per  anum. 
The  presence  of  such  substances  may  exite  extensive  ulceration  which 
will  lead  to  subsequent  stricture. 

An  infrequent  cause  of  direct  violence  to  the  rectum,  and  of  subse- 
quent ulceration  due  to  the  direct  injury,  and  independent  of  any  vene- 
real disease,  is  sodomy,  either  attempted  or  accomplished.  Burgeon' 
describes  the  rectum  of  an  idiot,  wlio  for  a  considerable  time  had  prac- 
tised this  vice,  as  much  dilated  and  infundibuliform  in  shape,  the  mu- 
cous membrane  as  blackish,  swollen,  and  ulcerated  in  spots  ;  and  the  sub- 
mucous and  muscular  layers  as  hypertrophied  to  four  or  five  lines  in 
thickness.  It  is  doubtful  whether  passive  pederasty  should  be  included 
among  the  causes  of  stricture,  as  the  injury  done  does  not  generally  reach 
to  thiff  extent  ;  and,  indeed,  the  anus  is  not  often  dilated  to  any  such 
extent  as  in  this  case.  Ligg"  describes  a  deaf-mute,  thirty-five  or  forty 
years  of  age,  the  victim  of  this  habit,  whose  anus  offered  no  trace  of 
traumutisnii,  and  was  well  closed,  being  marked  only  by  the  absence  of 
the  radiating  folds.  The  mucous  membrane  of  the  rectum  also  was  nor- 
mal. This  absence  of  the  radiating  folds,  together  with  the  presence  of 
spermatozoa  in  the  rectum  or  in  the  mucous  discharge  from  it,  are  given 
as  the  best  medico-legal  proofs  of  the  vice. 

An  injury  to  which  women  alone  are  subject,  and  which  is  believed 
by  many  to  go  far  towards  accounting  for  the  greater  frequency  of  ulcer- 
ation and  stricture  in  them  than  in  men,  is  bruising  of  the  rectal  wall 
between  the  head  of  the  foetus  and  the  sacrum  in  parturition.  Most  of 
the  standard  authors  mention  such  cases. 

An  ulcer  of  the  rectum  is  a  not  infrequent  result  of  surgical  interfe- 
rence with  diseases  of  this  part.  Although  in  certain  subjects  a  wound 
made  by  the  surgeon  may  refuse  to  heal  under  the  best  of  treatment, 
ulceration  from  this  cause  will  generally  be  found  to  be  due  to  careless 
or  ignorant  manipulation,  rather  than  to  the  unfortunate  constitutional 
state  of  the  patient.  Two  cases  occur  to  me  now:  one  of  a  large  ulcer, 
with  hard  and  elevated  edges,  looking  much  like  a  true  chancre,  which 
resulted  from  the  persistent  application  of  caustics  to  a  simple  fissure; 
and  another,  of  three  separate  ulcers  which  marked  the  former  site  of 
three  internal  hwinoiThoids  which  had  been  removed  by  ligatures.  The 
patient  suffered  only  slight  discomfort  from  the  operation,  and  was 
allowed  to  go  to  Ins  business  on  the  following  day — a  thing  which  may 
sometimes  be  done  with  apparent  impunity,  but  which  should  never  be 
countenanced  by  the  operator. 

The  application  of  nitric  acid  toprolap'^c  is  said  to  have  been  followed 
by  disastrous  ulceration  and  stricture,  but  such  need  not  be  the  case;  nor 


'  Bull,  de  hi  Sec.  Anat.,  1880,  p.  80. 
CJorr.  Bl.  f.  schweiz.  Aerzt«,  No.  8,  p.  71,  Feb.  Ist,  1879. 


160  DISEASES    OF    THE    RECTUM    AND    ANUS. 

is  any  such  use  of  the  acid  necessary  to  effect  a  cure  in  any  case  where  its 
use  is  indicated  at  all.  Prolaj^se  is  not,  however,  a  rare  cause  of  stric- 
ture, due  to  the  strangulation  and  sloughing  of  the  prolapsed  portion, 
and  to  the  subsequent  cicatrization. 

IrritaUe  Ulcer,  or  Fissure. — An  injury  due  to  any  of  the  causes 
already  mentioned  may,  in  certain  persons,  and  when  located  at  the  verge 
of  the  anus,  assume  the  characteristics  of  an  affection  which  has  been 
elevated  into  a  separate  class,  and  is  known  as  fissure,  or  irritable  ulcer. 
The  irritable  ulcer  differs  in  no  respect  from  other  simple  ulcers  in  the 
same  locality,  except  in  the  fact  of  its  irritability.  There  is  nothing 
peculiar  in  the  ulcer  itself.  It  may  be  due  to  a  slight  rent  in  the  mucous 
membrane  from  hard  faeces ;  to  a  congenital  narrowness  of  the  anal  orifice 
and  a  naturally  over-powerful  sphincter,'  to  the  irritation  of  a  leucor- 
rhoeal  discharge  in  women;  to  an  herpetic  vesicle,  or  to  the  venereal  sore 
which  it  so  strongly  resembles — the  soft  chancre.  Any  sore  which  is 
fairly  in  the  grasp  of  the  external  sphincter  is  apt  to  become  an  irritable 
or  painful  one;  and  a  fissure  may  be  painless  at  one  time  an^  painful  at 
another  in  the  same  person,  or  painless  in  one  person  and  painful  in 
another. 

For  this  reason  Gosselin'  has  divided  these  ulcers  into  two  distinct 
varieties,  the  tolerant  and  intolerant — a  classification  which  Molliere'  still 
further  improves  by  suggesting  the  words  tolerable  and  intolerable.  An 
ulcer  associated  with  contracture,  spasm,  irritability,  and  sometimes  with 
actual  hypertrophy  of  the  sphincter  is  what  is  known  as  an  irritable  one; 
and  without  this  condition  of  the  muscle  it  will  not  properly  come  under 
this  classification. 

This  contracture  of  the  muscle  may  be  temporary  or  permanent,  and 
is  due  to  the  irritation  of  the  sensitive  nerve  filaments  on  the  surface  of 
the  ulcer  by  the  passage  of  faeces,  and  to  the  reflex  action  excited  thereby; 
and  to  many  slighter  causes  such  as  laughing,  coughing,  sneezing,  or  posi- 
tion. It  may  even  come  on  spontaneously  in  persons  of  a  highly  nervous 
organization,  or  with  such  slight  provocation  as  to  appear  to  be  spontan- 
eous. 

There  are  two  well-known  theories  regarding  the  causation  of  this 
little  sore.  According  to  Boyer,*  the  foundation  of  the  trouble  is  a  spasm, 
of  the  sphincter  muscle,  and  the  fissure  is  merely  a  secondary  lesion  due 
to  the  passage  of  faeces  through  the  spasmodically  contracted  anus. 
Tiousseau,^on  the  other  hand,  reverses  the  relation,  and  very  properly, 
holding  that  the  fissure  exists  first,  and  that  the  spasm  of  the  sjihincter  and 


'  Sarremone,  These  de  Strasbourg,  1861,  No.  555,  Molliere,  p.  134. 

•  Diet,  de  Med.  et  de  Chirurg.  Prat.,  art.  Anus. 

»0p.  cit.,  p.  149. 

*Traite  des  Maladies  Chirurg.,  T.  x.,  p.  105. 

»  Clin.  Med.,  T.  iii.,  art.  Fissure. 


NON-MALIGNANT    ULCERATION.  161 

the  resulting  pain  are  reflex,  being  specially  apt  to  occur  in  persons  of 
neuralgic  tendency,  and  being  in  many  cases  merely  the  local  manifesta- 
tions of  a  general  nervous  state. 

Although  these  ulcers  are  generally  stated  to  be  due  to  an  actual  lace- 
ration of  the  raucous  membrane,  or  to  its  abrasion  from  some  irritation, 
they  not  unfrequently  originate  within  the  sinuses  of  Morgagni  and  a 
true  fissure  may  be  entirely  concealed  from  view  within  one  of  these 
pouches,  as  in  the  following  instructive  case  reported  by  Dr.  Vance' which 
for  brevity  I  will  slightly  condense. 

Case  XVI.— A  lady,  aged  18,  had  suffered  for  more  than  a  year  from 
all  the  symptoms  of  fissure,  had  been  frequently  examined  to  no  purpose, 
and  wiis  reduced  to  a  very  miserable  state.  On  examination  the  integu- 
mentary folds  were  congested,  thickened,  and  oedematous,  doubtless  as  a 
result  of  constant  scratching,  but  there  was  no  trace  of  anything  like  a 
fissure.  The  lining  membrane  was  searched  with  the  utmost  care,  but  no 
lesion  of  any  sort  was  revealed  except  slight  hypertrophy  of  the  sphincter. 
A  second  painstaking  review  of  every  part  of  the  rectum  gave  the  same 
result,  and  the  author  was  about  to  abandon  the  hope  of  finding  any  local 
lesion,  when  as  a  matter  of  form,  for  there  was  no  evidence  of  disease 
about  them,  he  determined  to  pass  a  probe  into  each  of  the  pouches. 
The  probe  could  not  be  forced  into  the  first  one,  and  with  the  second  he 
fared  no  better,  but  with  the  third,  after  an  ineffectual  attempt,  the 
probe  passed  into  the  sacculus. 

No  sooner  had  the  probe  entered,  however,  than  the  patient  screamed 
with  pain,  and  there  was  a  spasmodic  letraction  of  the  levator  ani  and 
sphincter  muscles  and  the  part  was  forcibly  withdrawn  from  view.  The 
site  of  the  sacculus  felt  as  if  a  buck-shot  liad  been  imbedded  in  the 
tissues,  so  hard  and  swollen  was  the  part.  A  small  probe-pointed  teno- 
tome was  carefully  passed  along  the  canal,  and  as  soon  as  the  sensitive 
point  was  touched,  the  handle  was  brought  down  and  the  edge  of  the 
knife  made  to  sever  tlie  inner  wall  of  the  sacculus  and  expose  the  diseased 
point.  This  done,  the  cause  of  the  suffering  was  revealed.  On  the  left 
side  of  the  anus,  and  at  a  point  where  there  had  been  no  unusual  sensi- 
bility, an  indurated  ulcer  had  formed  within  one  of  the  little  pouches. 
When  the  sacculus  was  opened  and  the  ulcer  exposed,  it  seemed  very 
much  like  an  ordinary  fissure  of  the  anus,  but  before  cutting  it  open  there 
was  no  evidence  wiiatever,  save  the  symptoms  the  patient  complained  of, 
to  indicate  tlie  existence  of  such  a  lesion. 

These  ulcers  are  generally  situated  at  the  posterior  commissure,  but 
may  be  found  anywhere  on  the  anal  circumference.  They  are  generally 
single,  but  when  of  venereal  origin  there  may  be  two  or  tliree.  They  are 
more  common  in  women  than  in  men,  because  constipation  is  more  common 
in  the  former  and  because  the  skin  is  finer.     They  are  confined  to  no  age 

'  Med.  and  Surg.  Reporter,  Aug.  14th,  1880. 
11 


162  DISEA.8ES    OF   THE    RECTUM    AND    ANUS. 

and  are  by  no  means  relatively  rare  in  infants.  They  are  generally  oval 
in  shape  with  their  long  axis  vertical,  and  involve  botli  skin  and  mucous 
membrane,  being  situated  just  at  the  junction  of  the  two.  In  some  cases 
they  have  the  appearance  of  a  simple  erosion,  in  others  of  on  old  ulcer 
with  grayish  base  and  indurated  edges  which  has  involved  the  whole 
thickness  of  the  mucous  membrane  and  extended  fairly  down  to  the  mus- 
cle beneath.  In  the  majority  of  cases  they  are  not  attended  by  suppura- 
ration  or  the  discharge  of  pus.  They  may  exist  for  years  without  gain- 
ing in  surface  or  depth.  Allingham'  has  pointed  out  how  commonly  they 
are  attended  by  small  polypi  situated  at  their  upper  end  or  on  the  oppo- 
site side  of  the  rectum;  and  they  will  often  be  found  in  conjunction  with 
haemorrhoids  and  condylomatous  tags,  the  dragging  upon  which  in  the 
act  of  defecation  has  seemed  to  me  in  some  cases  to  account  mechanically 
for  a  slight  tearing  of  the  mucous  membrane. 

An  eruption  of  herpes  around  the  anus,  similar  to  what  is  seen  on  the 
lips,  may  result  after  rupture  of  the  primary  vesicles  in  numerous  small 
superficial  ulcers  of  a  reddish  color  and  secreting  a  little  pus.  These 
may  coalesce  at  their  edges  and  form  a  serpiginous  sore.  They  are  apt  to 
be  accompanied  by  similar  eruptions  on  other  parts  of  the  body,  and 
must  be  carefully  distinguished  both  from  mucous  patches  and  soft  chan- 
cres. The  ulcerations  which  result  from  acute  and  chronic  eczema  and 
from  pruritus  present  no  special  characteristics.  They  are  generally  due 
to  the  injury  inflicted  by  the  nails  of  the  sufferer. 

From  what  has  been  said  of  the  etiology  of  these  simple  ulcers  it  is 
plain  that  they  must  present  many  variations  in  appearance ;  yet  the 
diagnosis  of  each  from  the  other,  and  of  the  whole  class  from  those 
which  are  to  follow,  will  not  generally  be  found  difficult  if  proper  atten- 
tion is  given  to  the  history,  the  appearance  of  the  lesion,  and  its  course. 
The  disease  is  generally  of  a  healthy  type,  and  tends  to  self-limitation 
and  spontaneous  cure  rather  than  to  increase.  The  ulcerative  action  is 
generally  superficial,  and  tends  to  extend  on  the  surface  rather  than  in 
depth.  It  is  generally  surrounded  by  the  signs  of  reparative  action,  and 
with  proper  care  will  undergo  cicatrization  which  when  extensive  will 
result  in  stricture. 

Tubercular  Ulcers. — There  are  two  varities  of  ulceration  met  with  in 
persons  of  the  tubercular  diathesis  ;  one  due  to  the  actual  deposit  and 
softening  of  tubercle,  the  other  a  simple  ulceration  containing  no  tuber- 
cular deposit,  but  modified  in  its  course  by  the  patient's  general  condition 
of  malnutrition.  The  former  may  properly  be  called  tubercular  ulcera- 
tion, and  the  latter  is  better  known  as  the  ulceration  of  the  tuberculous. 
The  former  is  very  rare.  It  may  occur  in  the  rectal  pouch  or  indeed  any- 
where along  the  course  of  the  alimentary  canal,  but  its  favorite  site  is  at 


'Op.  cit.,  p.  192. 


NON-MALIONAMT    ULCERATION.  163 

the  verge  of  the  anns  where  it  may  exist  before  any  general  manifestation 
of  tuberculosis. 

The  characters  by  which  such  an  ulcer  may  be  recognized  are  its  pale- 
red  surface  covered  with  a  small  quantity  of  scrum  but  devoid  of  healthy 
pus  and  apj^earing  as  if  varnished;  the  absence  of  all  surrounding  inflam- 
mation and  of  the  granulations  which  exist  in  a  healthy  sore;  its  ten- 
dency to  spread  in  depth  rather  than  on  the  surface;  the  absence  of  any 
marked  pain;  tiie  regular  outline  ending  abruptly  in  healthy  skin;  and 
above  all  its  chronicity  and  the  utter  failure  of  all  remedies  to  affect  its 
steady  course.  The  diagnosis  may  be  confirmed  by  the  microscope*  and 
the  disease  is  analogous  to  tuberculosis  of  the  larynx  which,  however,  has 
been  studied  much  more  thoroughly. 

Whether  such  an  ulcer  is  ever  a  cause  of  stricture  is  doubtful,  it  being 
doubtful  whether  a  truly  tubercular  ulceration  in  this  place  ever  heals, 
or,  in  other  words,  results  in  the  formation  of  contractile  tissue.  It  is 
exceedingly  difficult  to  induce  them  to  take  on  a  healthy  reparative 
action;  and  if  cicatrization  begins,  the  process  is  generally  incomplete, 
and  the  cicatrix  easily  breaks  down.  Sands,'  however,  relates  a  case  of 
stricture  in  a  boy  aged  eighteen  due  to  tubercular  deposit,  both  in  the 
rectum  and  peritoneum,  for  which  he  performed  colotomy,  the  deposit 
being  on  the  anterior  wall  at  the  level  of  the  pubic  symphysis,  and  the 
rectum  being  so  nearly  occluded  as  not  to  allow  of  the  passage  either  of 
an  instrument  or  an  injection.  On  autopsy,  a  portion  of  the  small  intes- 
tine seven  feet  long,  was  also  found  to  be  so  narrowed  as  to  admit  of  the 
passage  only  of  a  full-sized  bougie,  but  the  narrowing  in  both  cases  seems 
to  have  been  due  rather  to  the  encroachment  of  the  tubercular  mass  than 
to  cicatrization  and  subsequent  contraction. 

A  tubercular  ulcer  starting  in  the  wall  of  the  rectum  may  end  in  per- 
foration and  fistula  (fistula  with  largo  internal  opening),  and,  as  a  matter 
of  course,  the  usual  operation  in  such  a  case  would  be  followed  only  by 
disappointment.  Such  an  ulcer  has  also  been  known  to  cause  sudden 
death  from  haemorrhage  in  a  child,  aged  four  years,  the  subject  of  acute 
general  tuberculosis.* 

'  In  the  excellent  monograph  of  Pean  et  Malassez,  Etude  clinique  sur  les 
Ulcerations  anales,  Paris,  1872,  there  may  bo  found  the  history  of  a  case  of  this 
kind  with  tlie  microscopic  report  and  drawing  of  Cornil.  Goaselin  also  gives  a 
clinical  lecture  on  a  similar  case  in  the  Gaz.  Mtni.  do  Paris,  Mar.  27th,  1880,  call- 
ing attention  to  the  main  points  in  the  diagnosis  and  treatment;  and  Allingham 
speaks  of  cases  in  which  the  diagnosis  was  confirmed  by  Paget,  and  remarks 
parenthetically  that  the  disease  is  not  as  rare  as  is  generally  supposed.  Other 
literature  on  the  subject  may  be  found  in  Halx'rshon,  On  the  Diseases  of  the 
Abdomen,  London,  1862,  p.  302  et  seq. ;  in  MoUiere,  Traito  des  Maladies  dii  Rec- 
tum et  de  I'anus,  Paris,  1877;  Spill mann.De  la  tuberculization  du  tul)e  digestif 
(Tht^se  d'agregation  en  Medecine,  1878);  and  Lionville,  Bull.  Soc.  Anat.,  1874. 
'  N.  Y.  Met!.  Joum.,  April,  1865;  continued  in  December  number  of  same  year 
»  Ashby,  Trans.  Manchester  Med.  Soc..  Brit.  Med.  Journ.,  July  Slst,  1880. 


164  DISEASES    OF    THE    RECTUM    AND    ANUS. 

The  treatment  is,  therefore,  only  palliative,  though  Mollic^re'  pro- 
pounds the  interesting  question  whether,  if  such  an  ulcer  were  completely- 
extirpated  or  destro3^ed,  before  general  symptoms  of  tuberculosis  nad 
shown  themselves,  it  might  not  be  possible  to  prevent  the  general  mani- 
festation of  the  disease,  as  may  be  done  in  cases  of  tubercular  testis.  He 
bases  the  question  on  a  case  in  which  such  an  ulcer  existed  nearly  four 
years  before  any  other  sign  of  tuberculosis  was  apparent. 

The  other  variety  of  so-called  tubercular  ulcer  is  a  simple  sore  in  a 
phthisical  patient,  modified  in  its  course  and  characteristics  by  the  gen- 
eral condition.  It  may  result  from  any  of  the  causes  already  mentioned, 
and  any  of  the  varieties  already  described  may,  under  the  proper  condi- 
tions, assume  its  characteristics.  It  may  occur  either  within  the  rectum 
or  at  the  anus,  and  may  vary  in  size  from  a  mere  spot  a  quarter  of  an  inch 
in  diameter  to  a  sore  covering  the  whole  lower  part  of  the  rectum.  It 
may  extend  in  depth  as  well  as  on  the  surface;  may  perforate  and  cause 
abscess  and  fistula,  or  be  attended  by  thickening  of  the  wall  without 
decrease  in  calibre.  It  is  often  accompanied  by  numerous  polypoid 
growths;  it  is  generally  painful,  and  the  discharge  is  purulent.  It 
neither  extends  rapidly  nor  heals  easily,  and  yet  it  is  surrounded  by  a 
healthy  reparative  action,  and,  unlike  the  true  tubei-cular  sore,  it  may  be 
induced  to  heal,  and  is  one  of  the  causes  of  grave  stricture.  The  process 
is  essentially  a  chronic  one,  and  several  of  the  cases  of  "  chronic  ulcera- 
tion of  the  rectum  "  reported  by  Curling  come  properly  under  this  cate- 
gory. It  may  easily  be  distinguished  from  true  tubercle,  but  may  readily 
be  confounded  with  some  of  the  varieties  which  are  to  follow. 

Scrofula. — Allied  to  the  class  of  ulcers  last  named  are  those  in  which 
the  scrofulous  taint  manifests  itself,  as  it  may  do  either  in  follicular 
ulcers  of  the  rectum  and  large  intestine,  in  lupus  or  esthiomhie,  and  in 
rodent  ulcer.     The  last  two  affect  primarily  the  anus  and  perineum. 

Follicular  ulceration  is  due  to  a  chronic  inflammation  and  fatty  degen- 
eration of  the  follicles  of  the  rectum.  These  which,  when  first  affected, 
appear  as  small  caseous  nodules,  break  and  leave  small,  deeply  excavated 
ulcers,  which,  being  multiple,  may  coalesce  and  leave  larger  ones  of  the 
chronic  variety,  capable  of  subsequent  healing  with  the  formation  of  cica- 
tricial tissue. 

They  may  perforate  the  bowel  or  form  fistulae  of  the  blind  internal 
variety  when  low  down,  or  cause  peritonitis  Avhen  higher  up.  They  may 
be  only  one  of  many  manifestations  of  the  scrofulous  tendency  in  the 
same  patient,  and  they  frequently  co-exist  with  pulmonary  disease. 

Under  the  title  of  esihiomene  (lupus  exedens  of  the  ano- vulvar  region) 
a  number  of  phagedenic  ulcerations,  complicated  with  more  or  less  hyper- 
trophy of  the  nature  of  elephantiasis,  have  probably  been  described;  but,  in 
spite  of  the  confusion  of  statement,  this  would  seem  to  be  a  rare  manifes- 

'  Op.  cit.,  p.  651. 


NON-MALIGNANT   ULCEKATION.  165 

tation  of  scrofula,  which  may  precede  any  others  in  its  development.  It 
commonly  starts  from  the  external  organs  of  generation  in  the  female, 
and  invades  the  anus,  rectum,  and  vagina  secondarily.  It  is  almost  never 
seen  in  men.  Its  favorite  starting-point  is  in  the  perineum,  and  instead 
of  being  superficial,  it  may  be  perforating  and  produce  great  loss  of  tissue, 
turning  the  rectum  and  vagina  into  one  cavity.  At  this  stage  other 
ulcers  are  apt  to  appear  in  the  rectum  and  colon,  causing  diarrhoea  and 
sometimes  peritonitis;  but  whether  these  are  of  the  variety  just  described 
as  follicular,  or  are  due  to  further  deposits  of  lupus,  has  not  yet  been 
positively  decided. 

The  ulcer  is  irregular  in  outline,  with  a  granular  base  of  a  violet-red 
color;  and  there  is  a  slight  sanious  discharge.  The  edges  are  but  little 
elevated,  and  are  not  undermined,  and  there  is  more  or  less  hypertrophy 
of  the  surrounding  tissue  which,  in  some  cases,  is  exceedingly  well 
mai'ked.  The  ulcer  may  cicatrize  in  part,  the  cicatrix  being  thin  and 
white,  at  the  same  time  that  the  ulcerative  process  is  extending  in  the 
opposite  direction.  At  a  little  distance  from  the  ulcer  there  is  often  a 
pathognomonic  appearance  of  slight,  reddish,  hard  nodules  of  tubercular 
lupus,  separated  from  the  primary  sore  by  healthy  skin.  With  this 
amount  of  disease  the  constitutional  disturbance  is  often  not  suflBcient  to 
confine  the  patient  in  the  house. 

The  diagnosis  is  not  generally  difficult,  though  the  disease  may  be 
confounded  with  cancer,  phagedenic  chancroid,  and  with  elephantiasis 
with  secondary  ulceration.  It  is  best  distinguished  from  cancer  by  the 
cicatricial  bands  which  it  leaves  behind  in  its  ineffectual  attempts  at  heal- 
ing; and  from  chancroid  by  the  surrounding  tubercles  which  in  lupus 
develop  in  the  thickness  of  the  derma,  and  ulcerate  secondarily;  while  the 
ulcers  which  sometimes  surround  a  chancroid  are  ulcerous  from  the  first, 
being  due  to  secondary  inoculation.  Van  Buren  advances  the  theory 
that  most  of  these  ulcerations  are  due  to  the  grafting  of  the  syphilitic 
poison  upon  the  scrofulous  diathesis  in  women  of  improper  lives.  The 
duration  of  the  disease  is  indefinite,  and  it  seldom  leads  to  fatal  results. 
It  is  best  treated  by  destructive  cauterization  and  reclage.' 

Rodent  Ulcer  is  very  closely  allied  to  epithelioma,  and  may,  in  fact, 
be  considered  one  of  its  varieties ;  but  it  is  distinguished  from  it  clini- 
cally by  the  fact  that  it  does  not  infiltrate  surrounding  tissue,  does  not 
involve  the  lymphatics,  and  docs  not  become  generalized.  It  is  the  same 
disease  met  with  upon  the  face,  and  is  exceedingly  rare  at  the  anus, 
being  seen  only  twice  in  four  thousand  consecutive  cases  at  St.  Mark's 
Hospital. 

According  to  the  classical  description  of  Allingham,  it  is  found  by 
preference  at  the  verge  of  the  anus,  and  extending  from  this  i)oint  up- 

'  See  also  Huguier,  M^m.  Acad,  de  Med.,  1849;  Harday,  Scrofula  et  Scrojfu- 
lides,  P'  80;  and  Pean  et  Malasaez,  op.  cit. 


166  DISEASES    OF   THE   KECTUM   AND    ANUS. 

wards  into  the  rectum.  It  is  irregular  in  shape,  and  its  edges  end  ab- 
ruptly in  healthy  tissue.  Its  surface  is  red  and  dry  ;  it  destroys  superfi- 
cially, attacking  mucous  membrane  rather  than  skin,  and  undergoes 
rapid  but  only  partial  cicatrization  under  proper  local  and  constitutional 
treatment.  It  never  entirely  heals,  and  is  not  to  be  included  among  th& 
causes  of  stricture.  It  is  at  first  generally  mistaken  for  a  late  syphilitic 
manifestation,  but  is  distinguishable  from  it  by  the  powerlessness  of  all 
treatment  to  prevent  its  steady  progress.  It  is  one  of  the  most  painful 
of  all  the  ulcerative  affections  of  this  part,  and  ends  fatally,  unless  some 
other  disease  cuts  short  the  history.  It  is  best  treated  by  complete  exci- 
sion, and  this,  in  one  case  of  AUingham's,  secured  immunity  for  a  period 
of  four  years  during  which  the  patient  was  under  observation. 

Dysentery. — In  dysenteric  ulceration,  the  diseased  portion  of  the  lower 
bowel  becomes  infiltrated  with  fibrinous  exudation,  and,  as  a  result  of  the 
compression  which  this  exercises,  is  necrosed  and  sloughs.  When  the 
slough  is  cast  off,  there  results  a  loss  of  substance,  and  if  this  is  superfi- 
cial, the  membrane  may  regain  its  former  state  ;  but,  if  deep,  the  usual 
callous  cicatrix  is  produced  in  its  place,  and  stricture  is  the  result. 

The  ulcers  resulting  from  this  proces  vary  much  in  size,  location,  and 
appearance.  They  may  be  minute  circles,  but  are  generally  large,  and, 
though  their  favorite  site  is  the  rectum  or  sigmoid  flexure,  they  may  be 
found  anywhere  in  the  large  intestine.  They  may  extend  so  as  to 
coalesce  and  leave  only  islands  of  mucous  membrane  between  the  ex- 
tensive patches.  The  process  usually  involves  only  the  mucous  coat,  but 
may  extend  in  depth,  and  result  in  perforation  and  its  attendant  evils. 
The  coats  of  the  bowel  may  become  sinuous  abscesses,  so  that,  on  divid- 
ing the  prominent  portion  of  mucous  membrane  between  two  ulcers, 
several  drachms  of  pus  may  escape  (Habershon).  Although  all  the 
symptoms  of  dysentery  may  result  from  ulceration  due  to  other  causes,  as 
in  Annandale's  case,'  there  is  no  doubt  that  in  this  country  the  disease  is 
one  of  the  causes  of  chronic  ulceration  and  stricture,  and  Habershon  con- 
cludes that  the  disease  is  more  common  in  our  climate  than  is  generally 
supposed. 

In  the  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,* 
Dr.  Woodward  remarks  that  stricture  resulting  from  dysenteric  ulcera- 
tion seems  to  have  been  much  rarer  than  might  have  been  supposed,  and 
that  no  case  has  been  reported  at  the  Surgeon-General's  office,  either 
during  the  war  or  since;  that  the  Ai-my  Medical  Museum  does  not  con- 
tain a  single  specimen  ;  nor  has  he  found  in  the  American  medical  jour- 
nals any  case  substantiated  by  post-mortem  examination  which  this  con- 
dition is  reported  to  have  followed  a  flux  contracted  during  the  Civil 
War.     In  the  Amer.  Journal  of  the  Medical  Sciences,  for  April,  1881, 

^Brit.  Med.  Joum.,  1873,  p.  681. 
^Part  ii.,  voi.  i.,  Med.  Hist. 


NON-MAUGNANT    ULCEEATI©N.  167 

I  published  a  case  which  I  then  believed  came  under  that  category,  and 
the  subsequent  history  of  which  has  only  the  more  convinced  me  of  the 
correctness  of  the  diagnosis. 

Venereal  Ulcers. — Gonorrhoea  of  the  rectum  has  already  been  spoken 
of  under  the  head  of  proctitis.  Without  attempting  to  decide  upon  the 
.specific  character  of  the  inflammation  which  may  follow  the  contact  of 
of  gonorrhceal  virus,  it  may  be  well  to  call  attention  to  the  severity  of  that 
inflammation  and  to  the  fact  that  it  may  cause  ulceration  and,  probably, 
subsequent  stricture.  During  the  height  of  the  process,  the  rectum  is 
hot,  red,  swollen  and  granular,  and  there  is  an  abundant  purulent  dis- 
charge issuing  from  the  anus,  from  time  to  time  in  clots.  The  irritation 
of  this  may  cause  erosions  and  fissures  which  may  reach  a  considerable 
size;  or  a  previously  existing  fissure  may  become  inoculated  in  this  way 
and  spread  in  extent. 

Chancroids. — One  of  the  most  frequent  of  all  the  superficial  ulcera- 
tions at  the  anus  is  the  soft  chancre.  It  is  said  by  Pean  and  Malassez  to 
have  constituted  nearly  one-half  of  all  the  ulcerations  in  this  region  ex- 
amined at  the  Lourcine  in  1868.  It  is  much  more  common  in  females 
than  in  males,  constituting  one  in  nine  cases  of  chancroids  in  the  for- 
mer and  one  in  four  hundred  and  forty-five  in  the  latter.'  To  account 
for  this  greater  relative  frequency  only  two  things  are  necessary:  the 
frequency  of  accidental  contact  of  the  male  organ  in  coition  and  the 
facility  of  auto-inoculation  which  is  due  to  the  proximity  of  the  vulva  and 
vagina. 

These  ulcers  are  seen  either  on  the  skin  around  the  anal  orifice,  or 
just  within  the  canal,  and  show  a  decided  tendency  not  to  pass  above  the 
upper  border  of  the  internal  sphincter.  So  marked  is  this  trait  that  their 
existence  in  the  rectum  proper  /  as  been  denied,  and  the  mucous  mem- 
brane supposed  to  furnish  no  suitable  gi'ound  for  their  inoculation. 
They  may  be  single  or  multiple,  may  be  situated  at  any  point  in  the 
anal  circumference,  or  may  completely  surround  it.  In  one  case  of  my 
own,  the  anus  was  completely  surrounded  by  a  group  of  these  sores,  and 
the  ulceration  extended  from  the  posterior  commissure  backwards  in  the 
intergluteal  fold  its  whole  length,  as  far  as  the  base  of  the  sacrum,  being 
superficial,  however,  in  the  Avhole  of  its  course.  In  such  a  case  the  pain 
is  apt  to  be  severe ;  a  careful  examination  is  impossible  without  etlier, 
and  there  is  often  free  haemorrhage.  The  bleeding  at  the  time  of  defeca- 
tion was  the  chief  causo  of  alarm  to  the  patient  in  the  case  mentioned. 
These  sores  have  the  same  characteristics  as  the  soft  chancre  m  other 
parts  of  the  body.  The  class  of  women  in  whom  they  occur  is  always  an 
aid  to  the  diagnosis,  and  if  suspicion  as  to  their  nature  exists,  the  test  of 
auto-inoculation  may  always  be  tried. 

Sores  of  this  variety  tend  to  spontaneous  cure  with  cleanliness,  and,  if 

'  Foumier :  Diet,  de  Med.  et  Chirg.  Prat.  Art.  Chancre,  p.  72. 


168  DISEASES    OF    THE    RECTUM    AND    ANUS. 

necessary,  with  judicious  cauterization;  and  no  matter  how  completely 
they  may  have  involved  the  anus  or  the  skin  around  it,  they  seldom 
leave  any  traces  of  their  former  existence.  On  the  other  hand,  the  cure 
may  be  delayed  even  for  months,  and  the  sore  may  assume  a  chronic 
type,  due  either  to  the  existence  of  other  disease  in  the  rectum,  as 
haemorrhoids,  or  to  a  syphilitic  or  scrofulous  taint  in  the  patient.  They 
may  be  complicated  by  a  chronic  oedema  of  the  surrounding  parts,  and 
resemble  the  lupus  exedens  already  mentioned,  or  by  the  gangrenous 
process  known  as  phagedaena,  generally  of  the  chronic  variety,  and 
advancing  in  one  place  while  healing  in  another. 

And  now  we  come  to  the  debatable  ground  upon  which  so  much  has 
been  said  and  written,  and  about  which  much  still  remains  to  be  learned. 
Do  these  soft  chancres  ever  cause  stricture  of  the  rectum,  and  are  they 
the  most  common  cause  of  those  grave  strictures  so  often  met  in 
women  who  have  had  syphilis,  and  which  are  generally  known  as 
syphilitic?  In  the  light  of  our  present  knowledge,  and  yet  subject  to 
such  modifications  of  opinion  as  future  experience  may  teach,  we  shall 
answer  yes  to  the  first  of  these  questions,  and  no  to  the  second. 

That  a  soft  chancre  may  extend  into  the  rectum  and  cause  great 
destruction  of  tissue,  cicatrize,  and  leave  stricture,  is  beyond  doubt. 
A^an  Buren'  says,  "  I  have  certainly  seen  this  in  several  cases,  but  only  in 
women;"  Bumstead  and  Taylor^  speak  in  the  same  way;  Molliere^  says, 
"  Nevertheless,  the  soft  chancre  of  the  rectum  does  exist,  and  has  even 
been  seen  to  assume  frightful  proportions  in  this  deep  region;"  and 
Bridge's*  case  is  generally  considered  as  conclusive,  though  its  authority 
rests  much  more  upon  the  well-known  character  of  the  men  who  pro- 
nounced judgment  upon  it  than  upon  its  history  as  it  stands  recorded; 
for  there  is  at  least  a  strong  suspicion  of  syphilis,  and  there  is  no  account 
of  the  crucial  test  of  auto-inoculation. 

Dr.  Mason's'  paper  to  prove  the  chancroidal  nature  of  this  kind  of 
ulceration  and  stricture  has  this  great  advantage  over  the  similar  one  of 
Gosselm,"  that  he  leaves  the  reader  in  no  doubt  as  to  what  he  means  by 
chancroid,  and  unhesitatingly  adopts  the  dualistic  theory.  That  this  is 
not  the  case  in  tlie  latter  article,  the  reader  may  readily  convince  himself 
by  a  careful  perusal;  and,  for  my  own  part,  I  am  unable  to  see  where  in 
this  justly-celebrated  article  the  non-syphilitic  nature  of  the  affection  in 
question  is  taught,  for  the  author  leaves  us  in  absolute  ignorance  as  to 
which  of  the  two  at  present  well-known  varieties  of  "chancre  "  is,  in  his 


'Op.  cit.,  p.  243. 

S"  Venereal  Dis.."  Phila.,  1879. 

^Op.  cit..  p.  677. 

"*  Arch,  of  Dermatology,  Jan.,  1876. 

*  Amer.  Journ.  of  the  Med.  Sci.   Jan.,  1873 

«  Arch.  Geul.  de  Med. ,  18.54. 


NON-MALIGNANT    UIXJEBATION.  169 

opinion,  the  primary  cause  of  the  stricture;  and  it  is  rather  by  inference 
than  otherwise  that  his  "  chancre  "  is  interpreted  to  mean  chancroid. 

The  idea  left  on  the  mind  of  the  reader  is  not  that  the  disease  is  not 
syphilitic,  but  that  it  is  neither  a  primary,  secondary,  nor  tertiary  man- 
ifestation of  syphilis,  as  such  are  generally  understood,  but  something 
developed  in  the  neighborhood  of  the  primary  sore. 

Gosselin,  though  he  comes  nearer  to  it  than  had  ever  been  done 
before,  just  missed  enunciating  the  chancroidal  nature  of  these  strictures, 
though  Bassereau  had  distinguished  between  the  two  chancres  two  years 
before.  What  he  does  assert  is,  that  they  are  not  to  be  considered 
as  manifestations  of  constitutional  syphilis,  but  that  they  are  of  local 
character,  "  due  to  a  special  modification  of  the  vitality  of  the  tissues 
contaminated  by  the  virus  of  the  chancre,  comparable  to  the  lengthening 
and  hypertrophy  of  the  prepuce  with  contraction  of  its  orifice,  which 
follows  a  chancre  on  its  under  surface,  in  which  the  disease  is  evidently 
neither  an  oedema,  nor  a  specific  induration,  nor  a  constitutional  affec- 
tion, but  a  local  lesion,  due  to  the  presence  of  the  chancres,  and  con- 
secutive to  the  inflammation  which  they  have  caused."  In  the  same 
class  of  lesions,  he  places  hypertrophy  of  the  labia,  condylomata,  and 
other  vegetations. 

The  weight  of  the  evidence,  then,  is  decidedly  in  favor  of  the  occa- 
sional causation  of  stricture  by  the  chancroid.  But  that  all  of  the  many 
so-called  syphilitic  strictures  are  not  due  to  this  cause  is  rendered  certain 
by  the  fact  that  many  of  them  occur  in  women  above  the  suspicion 
cither  of  a  chancre  or  a  chancroid,  and  many  more  are  developed  late  in 
the  course  of  true  syphilis,  but  are  not  preceded  by  any  ulceration, 
chancroidal  or  otherwise,  at  the  anus,  and  have  their  starting-point  well 
above  the  sphincter  muscle.  Of  the  true  nature  of  these  we  shall  speak 
later. 

Chancre. — True  chancre  at  the  anus  is  not  very  uncommon.  Though 
Pean  and  Malassez  saw  only  one  case  at  the  Lourcine  in  1868,  they 
explain  the  fact  by  the  slight  local  disturbance  which  the  sore  causes — so 
flight  that  flio  sufferers  do  not  seek  treatment.  They  give  the  propor- 
tion in  this  place  as  compared  to  chancres  in  other  parts  of  the  body  as 
one  in  sixty-eight,  and  as  much  more  frequent  in  women  than  in  men 
(one  in  thirteen  in  the  former,  to  one  in  one  hundred  and  seventy-seven 
in  the  latter).  These  are  about  the  same  figures  reached  by  Jullien.  In 
the  female,  a  sore  in  this  locality  is  easily  accounted  for  by  accidental 
inoculation;  in  the  male,  it  means  sodomy.  They  are  most  likely  to  be 
mistaken  for  simple  fissures,  but  have  a  hard,  raised  outline  and 
indurated  base,  are  less  painful,  and  devoid  of  the  healthy  surface  of  the 
former.  In  any  case  of  susi^icion,  constitutional  treatment  should  be 
delayed  till  the  diagnosis  is  completed  by  the  appearance  of  general 
symptoms. 

True  chancre  within   tiie   rectum    is   very  rare    indeed.      Ricord, 


170  DISEASES    OF    THE    KECTUM    AND    ANUS. 

Foumier,  and  Vidal  de  Cassis  each  report  a  single  case,  and  in  the  latter 
the  induration  is  said  to  have  been  so  great  as  to  cause  stricture/ 
Molliere  carefully  analyzes  the  evidence  on  this  point  up  to  date,  and 
concludes  that  though  a  true  chancre  may  exist  within  the  rectum,  it 
never  causes  stricture,  for  the  reason  that  it  does  not  produce  any  great 
amount  of  ulceration,  and  that  the  induration  tends  to  spontaneous 
resolution,  or,  at  least,  rapidly  yields  to  the  influence  of  mercury.  The 
difficulties  surrounding  the  diagnosis  of  such  a  sore  are  manifest.  Its 
mere  appearance  would  scarce  be  conclusive,  and  in  women,  the  absence 
of  any  other  sore  which  might  cause  secondary  symptoms  would  need  to 
be  absolutely  proved — a  very  difficult  thing  to  do. 

Secondary  and  Tertiary  Syphilis. — One  of  the  secondary  manifesta- 
tions of  syphilis  is  to  be  looked  for  at  the  anus  and  rectum — the  mucous 
patch,  not  an  infrequent  sign  in  the  former  locality,  and  one  liable  to 
assume  ulcerative  action  from  local  irritation  or  inoculation  with  the 
virus  of  the  chancroid.  Generally,  however,  they  are  devoid  of  symp- 
toms, and  disappear  spontaneously  without  treatment,  or  simply  with 
cleanliness  and  the  use  of  an  astringent  wash.  That  the  mucous  patch 
may  appear  in  the  rectal  pouch  also  is  rendered  probable  from  analogy 
with  the  fauces,  and  such  cases  have  been  reported;"  but  as  they  never 
form  cicatrices,  they  must  be  counted  out  of  the  etiology  of  stricture. 

Tertiary  syphilis. — Well  marked  cases  of  tertiary  syphilitic  ulceration 
in  the  rectum  such  as  are  seen  in  the  mouth  and  throat  are  seldom  men- 
tioned; and  yet  that  they  may  exist  and  may  cause  extensive  destruction 
is  not  only  probable  from  analogy,  but  clinically  true.  Smith'  says,  "  I  am 
strongly  impressed  with  the  view  that  stricture  of  the  rectum  isjoroduced 
either  directly  by  tlie  specific  ulceration  in  the  part  affected,  or  by  contact 
of  the  discharge  from  the  surrounding  parts." — A  sentence  of  which  the 
the  last  clause  weakens  the  first,  for  the  question  is  not  whether  ulcera- 
tion may  be  set  up  in  the  rectum  of  a  syphilitic  person  by  the  irritation  of 
a  discharge  from  the  surrounding  parts,  but  whether  there  is  such  a  thing 
as  true  tertiary  syphilitic  ulceration  of  the  rectum. 

Curling*  describes  a  case  presented  by  the  late  Mr.  Aver^  at  a  meet- 
ing of  the  London  Pathological  Society,^  which  he  says  clearly  showed 
the  connection  of  the  lesion  with  syphilis.  "  Immediately  within  the 
anus,  which  was  surrounded  by  a  circle  of  vegetations,  the  ulcer  com- 
menced extending  three  inches  upwards,  and  occupying  the  whole  of  the 
internal  surface  of  the  rectum  to  that  extent.  The  edges  were  rough 
and  uneven  above,  and  below  soft  and  rounded,  the  whole  surface  was 
smooth,  exhibiting  the  muscular  fibres  of  tlie  intestine  quite  bare.     The 

'  Van  Buren. 

''  Molliere,  p.  641. 

^  Diseases  of  the  Rectum. 

*  Diseases  of  the  Rectum,  p.  112. 

5 Trans.  Path.  Soc,  vol,  i.,  p.  94. 


NON-MALIGNANT    CLCERATION.  171 

patient  died  with  numerous  indelible  marks  of  syphilitic  eruption  on  the 
limbs  and  trunk." 

Paget'  also  describes  a  case  very  fully  and  gives  the  main  points  by 
which  syphilitic  ulcers  may  be  distinguished  from  tubercular;  he  says 
"  The  whole  mucous  membrane  is  destroyed  except  one  small  patch  which 
IS  thickened  and  opaque.  The  exposed  submucous  surface  has  a  lowly- 
tuberculated,  undulating,  uneven  appearance,  and  is  thickened  by  infil- 
tration. In  the  early  stages  the  tissue  is  soft,  as  it  is  from  recent  inflam- 
matory effusion  or  oedema;  but  as  the  infiltration  organizes  it  hardens, 
becoming  callous,  with  fusion  of  the  mucous  and  submucous  coats,  and 
then  contracts  and  thus  brings  about  the  stricture.  The  affection  com- 
monly extends  from  the  anus,  as  if  by  continuity  with  the  excrescence 
(condylomata),  to  about  five  inches  up  the  rectum;  but  it  is  rarely  so 
marked  in  the  first  inch  of  the  rectum  as  it  is  higher  up." 

In  the  case  spoken  of,  there  were  also  ulcers  in  the  colon  which,  as  the 
patient  died  of  phthisis,  had  to  be  carefully  distinguished  from  tubercular 
disease.  He  says,  "  On  the  mucous  membrane  of  all  parts  of  the  colon 
there  are  ulcers  of  regular  round  or  oval  shape,  from  one-sixth  to  two- 
thirds  of  an  inch  in  diameter,  with  clean,  sharply  cut,  scarcely  thickened 
edges,  surrounded  by  healthy  or  only  too  vascular  mucous  membrane. 
Their  bases  are  for  the  most  part  level,  flat,  or  with  low  granulations 
resting  on  the  submucous  tissue,  nowhere  penetrating  to  the  muscular 
coat,  with  no  marked  subjacent  thickening  or  hardening.  On  some  of 
them  are  ramifying  blood-vessels;  on  some  few  there  is  at  the  centre  of  the 
base  a  small  island  of  mucous  membrane,  giving  to  the  ulcer  an  evident 
likeness  to  the  annular  syphilitic  ulcer  of  the  skin."  In  a  few  places 
they  had  coalesced  so  that  the  annular  shape  was  less  distinct.  In  the 
colon  they  were  continuous  with  those  in  the  rectum  which  Paget  conjec- 
tures to  have  been  originally  of  the  same  shape. 

The  diagnostic  marks  are  thus  given:  *'  These  ulcers  were  limited  to 
the  large  Intestine  and  decrease  in  size  and  number  from  the  rectum  up- 
wards— conditions  which  I  think  are  never  observed  in  tubercular  disease. 
There  is  not  a  trace  of  tubercle,  i.  e.,  of  circumscribed,  crude,  or  softening 
tuberculous  deposit,  in  the  submucous  or  any  other  tissue  of  the  intestine, 
none  in  a  Peyer's  patch,  or  at  the  base  or  edge  of  any  ulcer,  or  in  the  sub- 
peritoneal tissue  below  an  ulcer.  The  shape  and  other  characteristics  of 
the  ulcers  are  quite  unlike  those  of  intestinal  tuberculosis;  they  are  regu- 
lar; with  sharp,  even,  well-defined  edges,  with  level  bases;  they  are  not 
excavating,  nor  do  they  extend  through  the  submucous  tissue;  their 
edges  are  nowhere  eroded  or  undermined,  sinuous,  thickened,  or  brawny 
or  infiltrated;  the  subjacent  and  intervening  structures  appear  healthy 
'xcept  at  the  rectum.  Tliese  ulcers  are  not  grouped,  and  where  by  exten- 
onor  coalescence  they  have  lost  their  first  shapes  they  have  acquired  one 

'  Med.  Times  and  Gaz.,  1,  1865,  p.  279. 


172  DISEASES    OF    THE    RECTUM    AND    ANUS. 

altogether  irregular,  and  have  in  no  instance  even  tended  toward  that 
girdle-like  shape,  encircling  the  canal  of  the  intestine,  which  is  so  charac- 
teristic in  the  large  coalesced  tuberculous  ulcer.  Thus  by  negative  as 
well  as  by  positive  characters,  these  ulcers  are  clearly  distinguished  from 
the  tuberculous,  and,  as  I  have  said,  there  is  no  other  form  of  intestinal 
ulcer  to  which  they  bear  even  a  remote  resemblance." 

I  have  seen  two  cases  of  ulceration  in  syphilitic  women  where  I  could 
find  no  more  satisfactory  explanation  of  the  cause  than  the  presence  of 
this  constitutional  state.  In  both  the  disease  began  well  within  the  rec- 
tum and  not  at  the  anus,  which  is  rare  but  which  proves  that  they  were 
not  an  upward  extension  of  a  chancroidal  ulcer  at  the  anus;  and  in  both 
it  began  as  an  ulcer  of  the  mucous  membrane,  and  was  not  at  all  similar 
to  what  has  been  described  as  ano-rectal  syphiloma.  In  one  it  coincided 
with  a  late  syphilitic  eruption,  but  though  the  eruption  promptly  yielded 
to  general  treatment,  the  rectal  disease  did  not. 

A  strong  argument  in  favor  of  the  syphilitic  origin  of  many  cases  of 
ulceration  and  stricture  is  found  in  the  fact  that  a  large  proportion  of 
them  all,  nearly  one-half,  occur  in  persons  with  an  undoubted  syphili- 
tic history. 

Both  Smith  and  Paget  remark  on  the  occurrence  of  large  condyloma- 
tous  tags  of  skin  around  the  anus  in  these  cases  as  a  sign  of  value  in  the 
diagnosis  of  syphilis;  and  the  former  remarks  that  he  has  more  than  once 
made  the  diagnosis  of  syphilitic  stricture  from  their  presence  alone.  As 
a  sign  of  ulceration  and  probable  stricture  they  are  of  value;  but  they  can 
hardly  be  said  to  point  to  the  character  of  the  ulceration. 

The  ano-rectal  syphiloma  of  Fournier  (see  non-malignant  growths)  is 
not  primarily  an  ulceration,  but  like  the  gummata  it  leads  to  ulceration, 
and  according  to  him  it  is  the  most  common  cause  of  that  form  of  stric- 
ture which  is  called  syphilitic  and  which  we  have  spoken  of  in  connection 
with  the  chancroid.  It  is  primarily  an  infiltration  of  the  wall  of  the  rec- 
tum by  a  new  deposit  of  peculiar,  doughy,  inelastic  feel,  covered  by  shiny, 
livid  integument,  which  is  prone  to  break  down  into  ulceration;  and  it 
causes  stricture,  not  by  a  process  of  ulceration  and  subsequent  cicatriza- 
tion, but  by  an  actual  blocking  up  of  the  outlet  of  the  canal. 

Stricture. — Not  only  is  ulceration  a  common  cause  of  stricture,  but 
any  form  of  stricture  is  liable  by  its  obstructive  action  to  set  up  ulcera- 
tion in  the  wall  above. 

At  first  there  is  dilatation  of  the  rectal  pouch  and  hypertrophy  of  its 
walls,  due  to  the  effort  to  overcome  the  obstruction.  In  this  way  the 
coats  may  become  double  their  natural  thickness.  Next  an  ulcerative 
action  is  set  up  in  the  mucous  membrane,  probably  due  to  the  irritation 
and  traumatism  of  faeces.  Beginning  as  a  simple  congestion,  it  advances 
to  complete  destruction  of  the  tissue  over  the  whole  circumference  of  the 
bowel,  and  sometimes  for  several  inches  above  the  stricture.     As  a  result 


NON-MAUGNANT    ULCERATION.  173 

of  this  process  the  muscular  layer  may  be  entirely  denuded,  and  even 
perforated  at  a  point  high  above  the  original  disease. ' 

Gangrene. — The  gangrene  which  sometimes  follows  the  continued 

fevers  and  is  particularly  liable  to  affect  the  female  genitals,  and  the  more 

severe  forms  of  abscess  in  this  region  may  by  their  extensive  sloughing 

iid  in  subsequent  deformity  and  stricture.     The  following  case*  shows 

the  extent  of  the  ravages  which  may  be  caused  in  this  way. 

Case  XVIII. — Colored  woman,  aged  eighteen  years,  stated  that  six 
days  before  she  had  been  taken  in  labor  at  full  term,  and  was  delivered 
of  her  first  child  after  an  easy  labor  of  less  than  twelve  hours.  She  was 
left  after  delivery  in  a  soiled  condition  upon  the  filthy  bed  for  three  or 
four  days,  when  she  experienced  some  uneasiness  and  felt  some  pimples 
upon  the  vulva.  On  examination  on  admission  to  the  hospital,  the  labia 
were  found  swollen,  black,  and  sloughing;  and  escaping  between  them 
was  a  purulent  discharge  of  intensely  fcetid  odor,  mixed  with  the  urine 
which  constantly  trickled  away.  With  this  local  condition  these  was  as- 
sociated a  slight  fever,  and  small,  quick  pulse.  Eight  days  after  admis- 
sion, the  whole  vulva  and  vagina,  which  had  separated  at  its  junction  with 
the  uterus,  were  thrown  off,  leaving  a  deep  excavation,  five  inches  from 
above  downwards,  two  and  a  half  inches  across,  and  three  inches  in  depth. 
The  greater  portion  of  the  back  of  the  cavity  was  filled  with  a  globular 
body,  red  and  bleeding  when  touched,  which  was  taken  for  the  bladder. 
In  the  lower  portion  of  the  cavity  a  remnant  of  the  posterior  wall  of  the 
rectum  which  had  suffered  in  the  general  destruction  could  be  seen.  The 
slough  which  came  away  was  nearly  eight  inches  in  length  and  two  or 
three  in  thickness. 

This  disease  is  not  to  be  confounded  with  the  idiopathic  gangrenous 
cellulitis  already  spoken  of  under  the  head  of  abscess,  and  which  is  also, 
when  recovery  takes  place,  very  apt  to  result  in  subsequent  deformity 
and  stricture. 

Symptoms. — The  symptoms  of  what  is  known  as  the  irritable  ulcer  or 
fissure  are  so  well  marked  as  to  render  its  diagnosis  in  most  cases  easy. 
The  chief  is  the  peculiar  pain  which  may  be  constant,  but  is  always  in- 
creased by  defecation.  The  act  of  defecation  itself  may  not  be  notably 
painful,  but  after  the  act,  sometimes  almost  immediately,  sometimes  after 
a  shurt  interval,  the  characteristic  suffering  begins  and  may  last  in  mild 
cases  an  hour  or  two,  or  in  severe  ones  nearly  all  of  the  twenty-four 
hours.  The  pain  is  described  by  the  sufferers  as  dull  gnawing  and  aching 
rather  than  lancinating,  and  with  it  there  will  often  be  associated  neur- 
algic pain  in  the  loins  and  down  the  thighs. 

As  a  result  of  this  suffering,  at  first  periodic  and  later  constant,  a  very 

'  See  MolUere,  p.  294;  Gosselin,  loc.  cit.;  Lancereaux,  Bull,  de  la  Soc.  Anat., 
1859;  Malassez,  Diet.  Encyc.  p.  728. 

''  Dr.  Sparkiuan,  Trans.  South  Carolina  Med.  Ass..  1879. 


174  DISEASES   OF   THE   KECTUM    AND    ANUS. 

miserable  general  condition  is  often  developed.  The  sufferer  soon  learns  to 
dread  the  act  of  defecation  and  to  postpone  it  as  long  as  possible,  till  a  state 
of  chronic  constipation  is  produced  which  is  overcome  at  long  intervals  by 
purgatives;  and  in  this  way  the  whole  digestive  apparatus  is  thrown  out 
of  order.  In  women  also  there  is  apt  to  be  reflex  irritation  of  the  blad- 
der with  tenesmus;  and  in  men  there  may  be  spasmodic  stricture  of  the 
urethra.  In  womei;i,  also,  it  is  not  uncommon  to  find  uterine  trouble 
combined  with  that  at  the  anus.  It  is  sometimes  a  matter  of  amazement 
to  the  physician  to  see  how  long  a  woman  will  suffer  from  a  simple  sore 
of  this  kind,  and  to  what  a  condition  of  invalidism  she  will  allow  herself 
to  be  reduced  before  she  will  seek  for  aid.  The  struggle  between  femin- 
ine modesty  and  the  desire  for  relief  may  last  for  many  years  before 
common  sense  finally  gains  the  victory. 

It  will  sometimes  be  found  that  as  great  suffering  may  be  caused  by  a 
simple  erosion  at  the  anus  as  by  more  extensive  and  deeper  ulceration, 
and  indeed  the  amount  of  pain  is  not  at  all  indicative  of  the  depth  or 
extent  of  the  sore.  The  element  upon  which  the  pain  directly  depends 
is  probably  the  exposure  of  nerve-filaments.  Moreover,  the  susceptibility 
to  pain  varies  greatly  in  different  people,  and  a  woman  of  high  nervous 
organization  may  be  completely  invalided  by  a  sore  which  would  not  pre- 
vent a  laboring  man  from  attending  to  his  daily  avocations. 

It  must  be  remembered  in  this  connection  that  all  fissures  or  ulcers  in 
this  part  are  not  painful,  that  many  heal  spontaneously,  and  many  more 
exist  for  years  without  causing  any  particular  trouble. 

Ulceration  within  the  rectum  is  also  attended  by  a  certain  train  of 
symptoms  which  render  its  existence  extremely  probable,  and  which  in 
themselves  are  sufficient  to  denote  the  presence  of  an  ulcerative  process, 
though  throwing  little  light  upon  its  nature.  These  have  been  so  well 
described  by  Allingham  that  we  cannot  do  better  than  give  them  in  his 
own  words. 

"In  the  majority  of  these  cases,  the  earliest  symptom  is  morning 
diarrhoea,  and  that  of  a  peculiar  character,  in  my  opinion,  quite  indi- 
cative of  the  disease  [ulceration],  and  can  only  be  confounded  with 
cancer.  The  patient  will  tell  you  that  the  instant  he  gets  out  of  bed 
he  feels  a  most  urgent  desire  to  go  to  stool;  he  does  so,  but  the  result 
is  not  satisfactory.  What  he  passes  is  generally  wind,  a  little  loose  mo- 
tion, and  some  discharge  resembling  *  coffee-grounds '  both  in  color  and 
consistency;  occasionally  the  discharge  is  like  the  'white  of  an  unboiled 
egg' or 'a  jelly-fish;'  more  rarely  there  is  matter.  The  patient  in  all 
probability  has  tenesmus,  and  does  not  feel  relieved;  there  is  something 
of  a  burning  and  uncomfortable  sensation,  but  not  actual  pain;  before 
he  is  dressed  very  likely  he  has  again  to  seek  the  closet;  this  time  he 
passes  more  motion,  often  lumpy,  and  occasionally  smeared  with  blood. 
It  also  may  happen  that  after  breakfast,  taking  hot  tea  or  coffee,  the 
bowels  will  again  act;  after  this,  he  feels  all  right,  and  goes  about  his 


NON-MAMONANT    ULGEBATION.  175 

business  for  the  rest  of  the  day,  only  perhaps  being  occasionally  reminded 
by  a  disagreeable  sensation  that  he  has  something  wrong  with  his  bowel. 
.  .  .  After  this  condition  has  lasted  for  some  months,  more  or  less,  as 
influenced  by  the  seat  of  the  ulceration  and  the  rapidity  of  its  extension, 
the  patient  begins  to  have  more  burning  pain  after  an  evacuation,  there 
is  also  greater  straining  and  an  increase  in  the  quantity  of  discharge  from 
the  bowel;  there  is  now  not  so  much  jelly-like  matter,  but  more  pus — 
more  of  the  coffee-grouixi  discharge  and  blood.  The  pain  suffered  is  not 
very  acute,  but  very  wearying,  described  as  like  a  dull  toothache,  and  it  is 
induced  now  by  much  standing  about  or  walking.  At  this  stage  of  the 
complaint,  the  diarrhoea  comes  on  in  the  evening  as  well  as  the  morning, 
and  the  patient's  health  begins  to  give  way,  only  triflingly  so  perhaps, 
but  he  is  dyspeptic,  loses  his  appetite,  and  has  pain  in  the  rectum  during 
the  night,  which  disturbs  his  rest;  he  also  has  wandering  and  apparently 
anomalous  pains  in  the  back,  hips,  down  the  legs,  and  sometimes  in 
the  penis." 

We  need  scarcely  call  attention  to  the  extreme  gravity  of  this  condi- 
tion, or  to  the  certainty  with  which,  if  untreated,  and  sometimes  indeed 
in  spite  of  the  best  of  treatment,  it  will  end  either  fatally,  or  in  stric- 
ture which  will  require  the  gravest  surgical  procedures  for  its  relief. 
The  picture  is  unfortunately  a  familiar  one  to  every  general  practitioner, 
and  a  case  of  severe  or  extensive  ulceration  of  the  rectum,  is  perhaps  one 
which  calls  for  as  much  skill  in  treatment  and  yields  as  poor  results  as 
anything  in  the  range  of  surgery. 

Diagnosis. — The  diagnosis  of  the  existence  of  ulceration  is  generally 
easy  with  sufficient  care.  A  small  ulcer  within  the  grasp  of  the  external 
sphincter,  or  patially  concealed  within  one  of  the  sacculi,  may  easily  escape 
a  cursory  examination,  but  no  ulceration  within  four  inches  of  the  anus  is 
beyond  the  reach  of  actual  touch  and  vision,  and  none  need,  therefore, 
escape  detection  when  the  examination  is  properly  conducted.  In  many 
cases  the  diagnosis  is  plain,  the  sphincter  will  be  found  destroyed,  and 
the  rectum  and  vagina  will  present  one  common  cavity  of  foul  appear- 
ance, from  which  issues  a  foetid  purulent  discharge.  In  other  cases,  by  a 
careful  and  gentle  pulling  apart  of  the  lips  of  the  anus  and  a  gentle  strain- 
ing down  on  the  part  of  the  patient,  a  small  ulcer  within  the  grasp  of 
the  sphincter,  or  at  least  its  lower  edge,  will  be  brought  into  view  with- 
out the  use  of  the  speculum  or  ether.  In  others,  a  digital  examination 
will  reveal  an  eroded  painful  spot  within  the  rectum,  and  when  the  fin- 
ger is  withdrawn,  it  will  be  found  stained  with  blood.  In  all  such  cases 
the  diagnosis  is  easy;  in  others,  there  is  but  one  way  to  make  a  diagnosis, 
and  the  secret  of  success  will  be  found  in  the  two  words— ether  and  the 
speculum.  This  is  the  way,  I  am  sorry  to  say,  which  is  least  often  fol- 
lowed by  the  general  practitioner.  It  is  much  easier  to  give  a  lady  a 
diarrhoea  mixture  and  trust  in  Providence  for  a  cure  than  to  gain  her 
consent  to  take  ether  and  be  thoroughly  examined,  and  for  this  reason 


176  DISEASES    OF    THE    RECTUM    AND    ANUS. 

many  a  case  of  curable  disease  has  been  allowed  to  reach  an  incurable 
stage  before  its  existence  has  been  certainly  determined.  The  existence 
of  a  chronic  diarrhoea,  or  of  a  discharge  of  any  kind  from  the  rectum,  is 
always  a  good  and  sufficient  reason  for  a  thorough  physical  examination, 
and  with  ether,  .a  dilated  sphincter,  and  a  good  speculum,  no  one  need 
be  in  doubt  as  to  the  existence  of  ulceration  in  the  lower  part  of  the  rec- 
tum. 

The  existence  of  ulceration  being  decided,  its  nature  remains  to  be 
determined.  We  have  already,  in  speaking  of  the  different  varieties, 
given  some  of  the  chief  points  in  the  differential  diagnosis,  and  to  these 
we  must  again  refer  the  reader.  In  every  case,  the  history  must  be 
taken  into  account,  as  well  as  the  appearance  of  the  lesion.  Of  the  niany 
varieties  we  have  mentioned,  some  may  almost  certainly  be  excluded 
from  their  great  rarity.  Amongst  these  are  the  true  chancre,  the  tu- 
bercular deposit,  lupus,  and  rodent  ulcer.  In  the  majority  of  cases,  after 
excluding  syphilis,  the  ulcer  will  be  of  the  simple  variety  first  described, 
modified  more  or  less  by  the  general  condition  of  the  patient,  or  it  will 
be  malignant. 

Treatment. — In  speaking  of  the  treatment  of  ulceration  of  the  rectum 
and  anus,  we  will  first  deal  with  the  simplest  form,  the  irritable  ulcer,  and 
then  with  the  more  severe,  postponing  the  question  of  stricture  which  is 
the  most  frequent  result  of  severe  ulceration  to  a  separate  chapter. 

The  treatment  of  fissures  at  the  anus  should  in  the  first  place  be  pre- 
ventive in  those  persons  in  whom  the  skin  of  the  part  is  sensitive  and 
liable  to  cracks  and  small  sores;  and  for  such  there  is  nothing  better  than 
the  daily  washing  of  the  part  with  cold  water  and  a  soft  sponge,  and  the 
avoidance  of  anything  which  may  tend  to  irritate  it,  such  as  printed  or 
rough  paper  after  defecation. 

When  fissures  really  exist,  but  before  the  sphincter  has  become  irritable, 
they  may  often  be  cured  by  a  nightly  application  of  G-oulard's  liniment 
on  a  pledget  of  lint,  or  by  gently  touching  the  surface  with  a  solution  of 
nitrate  of  silver  to  coat  the  sore  (gr.  v.  orx. —  §  i.).  Allingham  strongly 
recommends  the  following  ointment  for  use  in  such  cases,  to  be  applied 
several  times  during  the  day. 

^6  Hyd.  subchlor gr.  iv. 

Pulv.  opii , gr-  ij- 

Ext.  belladonnas gr.  ij. 

Ungt.  sambuci §  i. 

The  occasional  light  application  of  the  solid  stick  of  nitrate  of  silver 
will  sometimes  effect  a  cure,  but  cauterization  should  be  used  with  great 
caution.  An  ointment  of  the  oxide  of  mercury  (  3  ss. —  3  i. )  will  sometimes 
prove  effectual  and  I  have  myself  been  very  well  satisfied  with  the  results 
obtained  by  the  occasional  passage  of  simple  hard  bougie  "well  oiled,  and 
allowed  to  remain  a  few  minutes  within  the  anus. 


NON-MALIGNANT   ULCERATION.  177 

With  these  local  measures  must  always  be  combined  the  greatest  pos- 
sible amount  of  rest,  and  the  daily  administration  of  a  mild  laxative  to 
insure  a  soft  evacuation.  If  there  is  already  considerable  pain  after 
defecation,  it  is  a  good  plan  to  have  the  bowel  emptied  before  going  to 
bed  at  night,  and  to  administer  an  opium  suppository  or  enema  after  the 
motion,  by  which  means  a  quiet  night  may  often  be  obtained.  An  oint- 
ment of  ext.  belladonna  may  also  be  used  for  the  same  purpose. 

By  such  means  as  these,  varied  according  to  the  requirements  of  each 
case,  a  fissure  or  superficial  ulcer  of  the  anus  may  generally  in  children 
and  often  in  adults  be  cured  before  it  reaches  the  stage  at  which  it  may 
properly  be  called  irritable.  But  after  this  stage  has  once  been  reached, 
there  is  no  longer  any  tendency  on  the  part  of  nature  toward  spontaneous 
cure;  and  except  the  rest  and  laxatives  which  are  important  adjuvants  to 
all  treatment,  they  may  as  well  be  abandoned  for  more  active  measures. 

The  method  of  cure  which  at  the  present  time  has  succeeded  all  others 
in  these  cases  and  which  is  so  invariably  successful  as  to  leave  little  to  be 
desired  consists  in  temporarily  paralyzing  the  sphincter  muscle  by  stretch- 
ing it,  the  patient  being  under  ether.  This  is  an  outgrowth  of  the  ori- 
ginal operation  of  Boyer,'  which  consisted  in  completely  dividing  the 
muscle  with  the  knife.  Syme  saw  that  this  was  unnecessary,  and  substi- 
tuted for  it  the  division  of  those  fibres  of  the  muscle  which  formed  the 
base  of  the  ulcer,  an  operation  equally  effectual  and  in  every  way  prefer- 
able to  the  other,  involving  no  danger  of  permanent  loss  of  power  of  the 
muscle,  inasmuch  as  its  fibres  are  not  completely  divided.  Dumarquay* 
also  proposed  another  substitute  which  he  believed  would  succeed  where 
other  measures  failed  and  which  consists  in  a  subcutaneous  section  of  the 
muscle  by  passing  the  knife  first  between  the  mucous  membrane  and  the 
muscle  and  then  cutting  till  the  muscle  gave  way  very  much,  as  the  tendo 
Achillis  may  be  felt  to  do  when  similarly  operated  upon.  The  objections 
to  this  procedure  are  the  occasional  occurrence  of  suppuration  in  spite 
of  the  greatest  care;  and  the  risk  of  a  concealed  haemorrhage  which  may 
be  none  the  less  severe  and  infiltrate  the  parts  with  blood. 

The  operation  of  stretching  was  originally  performed  by  Recamier 
and  as  performed  by  him  consisted  rather  in  a  thorough  kneading  of  the 
muscle  with  the  fingers  than  in  stretching;  and  this  was  once  again  im- 
proved upon  by  Maisonneuve*  who  brought  it  to  essentially  its  present 
condition.     This  operation  has  been  already  described. 

In  fissures  complicated  with  polyjii,  the  polypus  must  always  be 
removed  at  the  time  of  the  operation;  and  in  women  suffering  from  the 
union  of  uterine  and  vesical  trouble  with  painful  ulcer,  the  uterus  must 


•  Traite  dea  Maladies  Chirurg.,  etc.,  t.  x.,  Paris,  1831. 
« Arch.  Genl.  de  Met!.,  1846. 
•Clin.  Chirurg.,  t.  ii.,  p.  1864. 
12 


178  DISEASES    OF    THE    RECTUM    AND    A_NU8. 

be  treated  as  well  as  the  ulcer,  or  the  operation  on  the  latter  will  be  apt 
to  fail. 

In  eases  where  the  patient  refuses  to  take  ether,  the  operation  of 
drawing  a  sharp  knife  through  the  ulcer  and  muscular  fibres  directly  be-' 
neath  it  may  sometimes  be  performed  quickly,  and  with  only  momentary 
pain.  It  is  customary  to  use  a  fenestrated  speculum  in  such  an  opera- 
tion, but  it  may  easily  be  dispensed  with  when  a  straight,  blunt-pointed 
knife  is  used.  The  knife  should  be  very  sharp,  and  the  operation  must 
be  skilfully  done,  but  when  properly  done  it  is  usually  successful. 

It  is  not  necessary  to  cut  entirely  through  the  sphincter,  and  yet  those 
fibres  of  it  which  form  the  base  of  the  ulcer  should  be  fairly  divided,  for 
it  is  by  putting  an  end  to  the  contractions  of  these  fibres  that  the  opera- 
tion works  its  cure.  The  operation  should  always  be  extensive  enough 
to  produce  a  certain  amount  of  relaxation  of  the  muscle. 

The  most  frequent  cause  of  failure  in  any  of  the  procedures  commonly 
employed  for  the  cure  of  fissure  is  the  presence  of  a  small  polypus  or  an 
external  hsemorrhoidal  tag  in  connection  with  the  sore.  These  should 
always  be  searched  for  with  great  care,  hence  with  a  speculum,  and  should 
always  be  removed  when  found.  Otherwise  neither  stretching  nor  division 
of  the  sphincter  will  be  of  much  avail. 

Note.— Kjellberg  (Nordiskt  Med.  Arkiv,  Bd.  VIII.,  Heft  4)  has  called  atten- 
tion to  the  comparative  frequency  with  which  fissure  is  met  with  in  children, 
which  he  believes  to  be  much  greater  than  is  generally  supposed.  In  9,098  chil- 
dren brought  to  the  Polyklinik  of  Stockholm,  it  was  found  128  times;  60  of  the 
cases  were  boys  and  68  girls.  The  majority  were  under  one  year  of  age  and  73 
under  four  months.  The  symptoms  resemble  those  in  the  adult,  but  are  less 
severe,  and  the  treatment  is  the  same,  care  being  taken  to  remove  anything  which 
may  act  as  a  cause  of  the  trouble,  such  as  constipation,  worms,  rectal  catarrh, 
etc. 

The  treatment  of  ulceration  within  the  rectum  is  a  much  more  diffi- 
cult matter  than  the  treatment  of  that  at  the  anus,  and  yet  m  principle 
they  are  the  same.  In  both  we  give  the  ulcer  rest,  and  try  to  assist 
nature  in  her  own  methods  by  avoiding  anything  which  shall  interfere 
with  the  process  of  repair.  The  treatment  of  ulcer  of  the  rectum  may 
therefore  be  summed  up  in  two  words,  rest  in  bed  and  fluid  diet.  I  do 
not  think  I  exaggerate  when  I  say  that  these  alone  will  cure  most  cases 
that  are  curable,  and  that  without  them  no  treatment  is  likely  to  be  of 
much  avail. 

The  rest  in  bed  must  be  absolute,  and  is  not  such  rest  as  is  usually 
considered  by  ladies  to  be  compatible  with  a  morning  bath,  a  rather  elab- 
orate toilet  while  standing  before  the  mirror  and  walking  round  the 
room,  and  a  final  sitting  down  to  comparative  quiet  in  an  easy  chair  or 
on  a  lounge  for  a  part  of  the  day  till  the  reverse  of  the  performance  is 
repeated.  Rest  in  these  cases  means  rest  in  bed  for  weeks  at  a  time,  and 
the  line  should  be  drawn  on  exercise  at  just  what  is  necessary  for  the  use 


NON-MALIGNANT   ULCERATION.  179 

of  the  commode  which  is  brought  into  the  room  and  placed  by  the 
patient's  bed  when  necessary.  After  considerable  experience  I  have 
found  it  easier  to  begin  right  in  these  cases  than  to  waste  a  couple  of 
months  while  the  patient  is  half  resting,  and  then  have  to  come  to  it  in 
the  end;  and  have  again  and  again  been  surprised  to  see  how  quickly 
reparative  action  will  begin  in  the  one  case,  and  how  long  it  may  be  de- 
layed in  the  other.  An  hour's  walking  and  standing  around  the  sick- 
room will  undo  more  than  the  other  twenty-three  can  gain. 

This  point  being  carried  to  the  surgeon's  satisfaction,  the  milk-diet 
need  not  be  so  absolute;  but  may  be  varied  with  soups  and  easily  digested 
solids,  iis  bread  and  crackers;  care  being  taken  to  secure  soft  and  unirri- 
tating  passages.  "With  such  diet  as  this,  it  will  sometimes  happen  that  a 
movement  of  the  bowels  every  two  or  three  days  will  be  all  that  nature 
requires,  and,  as  long  as  such  a  condition  causes  no  uneasiness,  I  am  not 
accustomed  to  interfere  with  it  by  laxatives. 

In  cases  where  it  is  well  borne,  cod-liver  may  be  administered  both  as 
food  and  laxative,  often  with  excellent  effect  upon  the  general  condition 
and  the  local  trouble. 

In  the  way  of  local  applications  suppositories  answer  the  best  purpose. 
The  menstruum  should  be  of  some  substance  which  may  be  easily  dis- 
solved at  the  temperature  of  the  body;  and  in  the  way  of  drugs  I  have 
had  more  satisfaction  with  bismuth  and  iodoform  than  with  anything 
else.  The  practice  of  introducing  local  remedies  in  this  form  has  many 
advantages  over  that  of  applying  them  by  means  of  a  speculum,  because 
a  speculum  examination  of  an  ulcerated  rectum,  repeated  two  or  three 
times  a  week,  is  apt  to  do  more  harm  by  its  mere  introduction  than  the 
remedies  will  do  good.  The  utmost  gentleness  must  be  used  in  all  cases, 
and  the  greatest  care  is  necessary  to  keep  from  irritating  tha  part.  I 
have  also  found  it  well  to  mix  about  the  tenth  of  a  grain  of  morphine 
with  the  suppository,  and  administer  this  at  night  and  morning.  It  cer- 
tainly ministers  to  the  local  rest  of  the  part,  and  it  renders  rest  in  bed 
much  more  endumble  in  persons  of  a  nervous  tendency. 

Certain  good  results  may  be  gained  by  applications  to  the  ulcerated 
spot  by  means  of  enemata,  and  when  the  disease  is  situated  high  up,  the 
amount  of  fluid  injected  should  be  large.  Three  pints  of  water  may  be 
thrown  into  the  upper  part  of  the  rectum,  the  sigmoid  flexure,  and  the 
lower  part  of  the  colon,  if  the  proper  means  be  adopted,  without  causing 
any  uneasiness  at  the  time  or  any  subsequent  desire  for  an  evacuation. 
Long,  flexible,  soft-rubber  tubes  may  now  be  obtained  from  any  of  the 
surgical  instrument-makers,  which  are  suitable  for  this  purpose.  The 
tube  should  be  small  and  the  ojiening  in  it  just  large  enough  to  hold 
securely  tiie  smallest  end-piece  of  an  ordinary  Davidson's  syringe.  The 
injection  should  be  given  Avith  the  patient  on  the  side,  and  given  slowly. 
The  drug  from  which  the  best  results  may  be  expected  when  used  in  this 
way  is  the  nitrate  of  silver,  and  the  solution  should  vary  in  strength  from 


180  DISEASES    OF    THE    RECTUM    AND    ANUS. 

twenty  to  forty  grains  to  three  pints  of  water.  This  plan  of  treatment  has 
recently  been  very  successfully  employed  in  cases  of  dysenteric  ulcera- 
tion. Dr.  Mackenzie'  reports  five  cases  of  cure  by  it,  and  in  one  of  them, 
where  the  disease  had  lasted  two  years  and  a  half,  the  cure  followed  a 
single  injection. 

The  knife  may  serve  a  good  purpose  under  several  circumstances. 
Where  the  sore  is  of  small  dimensions  and  well-limited  in  outline,  even 
though  it  be  above  the  external  sphincter,  it  is  sometimes  of  advantage  to 
draw  the  knife  across  the  muscular  fibres  which  form  its  base,  and  secure 
rest  for  it  in  this  way.  The  operation  is  one  of  delicacy,  but  is  also  one 
which  may  assist  gi*eatly  in  the  cure. 

In  cases  of  more  extensive  disease  above  the  sphincter  and  at  its  level, 
where  the  latter  by  its  action  causes  constant  pain  and  suffering  (:ind  in- 
deed ulceration  of  the  rectum  is  seldom  very  painful  unless  the  sphincter 
is  involved,  and  in  advanced  cases  where  it  has  been  entirely  destroyed, 
may  be  almost  painless),  I  am  in  the  habit  of  freely  dividing  that  muscle 
in  the  median  line  posteriorly  by  a  single  incision  through  all  its  fibres. 
In  this  way  relief  is  given  to  suffering,  more  perfect  rest  is  obtained  than 
is  otherwise  possible,  and  a  way  is  opened  for  such  further  local  treat- 
ment as  may  be  necessary. 

The  operation  may  be  followed  by  incontinence,  though  it  is  not  apt 
to  be  if  the  incision  is  in  the  median  line,  so  that  the  nerves  are  not  im- 
plicated, and  if  the  internal  sphincter  be  not  involved  in  the  incision. 
The  operation  is  preferable  to  that  of  stretching  the  muscle  simply, 
because  its  effect  is  more  permanent;  and,  indeed,  is  a  substitute  for 
colotomy  in  the  same  class  of  cases.  Of  this  operation  I  shall  say  more 
in  the  next  chapter  when  speaking  of  the  most  frequent  secondary  effect 
of  ulceration — stricture. 


'  On  the  Treatment  of  Chronic  Dysentery  by  Voluminous  Enemata  of  Nitrate 
of  Silver.    The  Lancet,  April  22d,  29t'h,  1882. 


NON-MAUGNAJST   STKICTURE    OF   THE    RECTDM.  181 


CHAPTER   X. 

NON-MALIONAin'  STRICTUBE   OF  THE   RECTUM. 

Stricture  due  to  Changes  in  the  Rectal  Wall  and  to  Pressure  from  Without. — 
Spasmodic  Stricture. — (General  Division  into  Venereal  and  Non- Venereal  Stric- 
tures and  into  Fibrous  and  Cicatricial — Frequence  of  Syphilis  in  Connection 
with  Stricture. — Non-Venereal  Strictures. — Congenital,  Dysenteric,  Trauma- 
tic, Varieties. — Stricture  from  Hypertrophy  of  Valves. — Pathological  Anat- 
omy.— Changes  in  Rectal  Wall  above  and  below  the  Stricture. — Changes  in 
Parts  around  the  Stricture. — Symptoms. — Value  of  Flattened  Passages  as 
Symptom. — Signs  of  Obstruction. — Obstruction  with  Stricture  of  Consider- 
able Calibre. — Diagnosis. — Dangers  to  be  Avoided  in  Examination. — Diffi- 
culty when  Disease  is  Situated  high  up  in  the  Bowel. — Use  of  Bougie  for 
Diagnosis. — Treatment. — Advisability  of  Anti-Sj-philitic  Medication. — Pallia- 
tive Treatment.— Medicinal  Treatment  of  Threatened  Obstruction. — Surgical 
Measures. — Dilatation,  Gradual  or  Sudden. — Rules  for  Gradual  Dilatation. — 
Divulsion,  Dangers  of,  and  Methods  of  Performing. — Treatment  by  Free 
Division. — Description  of  Operation. — Collection  of  Cases.— Results  of  this 
Treatment. — Comparison  with  Colotomy. — Cases  from  Author's  Practice. — 
Knife  for  Operation. — Excision  of  Non-5Ialignant  Stricture. — Colotomy. — 
Restrictions  to  the  Operation. — General  Considerations  Regarding  it. — 
Treatment  of  Stricture  High  Up. 

A  STRICTURE  of  the  rectum  may  be  due  either  to  a  change  in  the  wall 
of  the  bowel  or  to  pressure  from  without.  A  tumor  of  any  kind  in  the 
pelvis  will  not  infrequently  press  upon  the  rectum  so  as  to  obstruct  its 
calibre.  An  abscess  in  the  ischio-rectal  fossa  may  be  accompanied  by  an 
amount  of  inflammatory  deposit  around  the  rectum  sufficient  to  obstruct 
it;  and  a  pelvic  inflammation  in  women  may  be  accompanied  by  an  exu- 
dation which  in  the  form  of  bands  across  the  bowel  shall  partially  close 
it,  and  at  the  same  time  lead  to  compensatory  muscular  hypertrophy  of 
the  rectal  wall.  Medical  literature  is  full  of  cases  of  this  nature,  and  here 
it  is  only  necessary  to  refer  to  them  as  a  not  infrequent  cause  of  obstruc- 
tion both  of  the  rectum  and  of  other  parts  of  the  canal. 

Much  has  been  written  in  times  past  upon  the  question  of  spasmodic 
stricture  of  the  rectum,  but  at  present  the  condition  is  looked  upon  by 
the  best  authorities  with  great  doubt,  if  not  with  absolute  unbelief. 
Spasmodic  contraction  or  stricture  of  the  external  sphincter  is  not  an 
unusual  condition,  and  cases  of  it  from  my  own  practice  and  that  of 


182  DISEASES    OF    THE    RECTUM    AND    ANUS. 

others  will  be  reported  further  on;  but  spasmodic  stricture  of  the  canal 
above  this  point  has  always  been  a  matter  of  belief  and  assertion  rather 
than  of  demonstration. 

Allingham  upholds  its  existence  in  connection  with  organic  stric- 
ture, as  a  complication  of  the  latter,  and  gives  the  following  case  as  proof. 
He  says:  "There  are,  no  doubt,  many  cases  of -strictui'O  in  which  there 
is  very  little  deposit  and  much  spasm;  and  there  are,  on  the  other  hand, 
cases  where  much  obstruction  exists,  but  very  little  spasm.  A  patient 
under  my  care  at  St.  Mark's  had  a  stricture  so  tight  that  I  could  not 
make  the  point  of  my  little  finger  enter  it;  on  putting  her  under  the 
full  influence  of  chloroform,  I  could  get  two  fingers  through  without 
difficulty." 

This  case,  if  it  be  admitted,  as  it  generally  will  be  on  so  good  author- 
ity, actually  proves  more  than  has  ever  been  proved  before  with  regard  to 
this  question,  and  is  about  the  only  one  which  really  proves  anything. 
I  have  already  referred  to  the  difficulty  which  often  exists  in  passing  a 
rectal  bougie  from  the  natural  conformation  of  the  parts.  It  is  upon 
this  difficulty  that  nearly  all  the  arguments  for  and  the  supposed  cases  of 
spasmodic  stricture  rest.  When  the  bougie  cannot  be  passed,  a  spasmodic 
stricture  is  supposed  to  be  the  cause.  When,  after  numerous  trials,  by 
a  lucky  manipulation  an  entrance  is  effected,  the  spasm  has  been  over- 
come. To  this  may  be  reduced  nearly  all  the  reported  cases  of  this  affec- 
tion which  from  time  to  time  have  appeared  in  the  writings  of  those 
who  have  devoted  attention  to  the  subject. 

Molliere,'  Avith  his  usual  happy  style,  has  gone  very  nearly  to  the  bot- 
tom of  this  question.  He  says  that  at  a  not  very  remote  period  there 
flourished  by  the  side  of  Ashton,  Curling,  and  the  surgeons  of  St. 
Mark's  Hospital  certain  specialists  as  expert  in  finding  strictures  in  the 
rectum,  as  are  our  laryngologists  in  discovering  polypi  in  the  larynx. 
These  estimable  practitioners  gave  themselves  up  to  the  daily  exercise  of 
dilatation  by  bougies,  and  to  facilitate  the  practice,  one  of  them  had 
invented  a  pair  of  pants  of  a  special  pattern,  dressed  in  which  novel 
livery  his  patients  came  daily  to  have  a  sound  introduced  into  the  anus. 

Another  anecdote  is  repeated  by  several  authors  which  illustrates  the 
ease  with  which  patients  may  deceive  themselves  or  be  deceived  by  others 
in  this  matter. 

A  lady  went  to  consult  a  rectologist  for  some  reason  or  other  which 
is  not  stated,  and  a  sound  was  introduced  into  her  anus.  Her  husband 
learning  this,  rushed  to  the  house  of  the  scoundrel  in  a  violent  rage 
and  armed  with  a  whip.  Half  an  hour  later  he  returned  disconsolate. 
He  had  found  out  that,  like  his  wife,  he  had  a  stricture  of  the  rectum, 
and,  like  her,  he  had  submitted  to  catheterization. 

This  whole  question  of  spasmodic  stricture  has  been  very  ably  dis- 

'  Loc.  cit.,  p.  320. 


NON-MALIGNANT   STRICTURE   OF   THE    RECTUM.  183 

cussed  by  Van  Buren,'  and  if  the  reader  wishes  to  follow  it  further,  he 
can  scarcely  do  better  than  to  consult  that  article.  Uncomplicated  spas- 
modic stricture  of  the  rectum  is  a  thing  whose  existence  is  not  admitted 
by  the  best  authorities,  and  which  will  seldom  be  found  by  a  skilful  ex- 
aminer. It  is  perhaps  too  much  to  say  that  it  never  exists,  but  a  well- 
marked  case  of  it  within  easy  reach  of  the  finger,  which  could  be  plainly 
detected  by  an  ordinary  examination,  and  which  disappeared  under 
chloroform,  is  what  those  who  do  not  believe  in  its  existence  are  calmly 
waiting  to  see. 

The  changes  in  the  wall  of  the  rectum  which  may  cause  stricture,  in- 
dej^ndent  of-  malignant  disease  which  will  be  considered  later,  may  be 
divided  into  the  two  general  classes  of  venereal  and  non-venereal,  and 
each  of  these  may  be  again  divided  into  the  cicatricial  and  fibrous. 

Venereal  Stricture. — In  the  chapter  on  ulceration  stricture  has  been 
frequently  referred  to  as  a  not  infrequent  consequence  of  that  process, 
and  the  various  forms  of  ulceration  which  by  subsequent  cicatrization 
were  capable  of  producing  this  result  have  been  mentioned.  In  a  general 
way  it  may  be  said  that  any  ulcer  which  destroys  even  the  thickness  of 
the  mucous  membrane  to  any  extent  will,  when  healed,  leave  a  cicatrix, 
and  if  such  a  cicatrix  be  at  all  extensive  it  will  by  its  contraction  cause 
subsequent  diminution  in  the  rectal  calibre. 

It  has  been  shown  that  many  of  the  more  severe  forms  of  rectal  ulcera- 
tion are  of  venereal  origin.  The  venereal  sores  capable  of  producing  a 
stricture  are  the  chancroid,  and  the  later  syphilitic  ulcers.  We  shall 
leave  out  of  consideration  the  true  chancre,  and  the  mucous  patch,  for 
the  reason  that  their  influence  in  the  causation  of  stricture  is  still  rather 
a  matter  of  surmise  tlnin  of  proof,  and  the  same  thing  may  be  said  re- 
garding gonorrhoea  of  the  rectum. 

For  a  description  of  these  ulcerative  venereal  processes  the  reader 
may  again  refer  to  the  chapter  on  ulceration;  but  there  is  a  class  of  vene- 
real strictures  which  are  syphilitic,  but  are  not  primarily  ulcerative  and 
therefore  not  cicatrical.  In  this  class  are  to  be  placed  the  gummata,  the 
ano-rectal  syphiloma  which  differs  from  gummy  deposit  rather  clinically 
than  microscopically,  both  of  which  have  already  been  described;  and  a 
third  late  manifestation  of  constitutional  syphilis,  which  is  an  inflamma- 
tion of  the  rectal  wall.  This  inflammatory  change  may  involve  a  large 
portion  of  the  rectum.  It  begins  in  the  muscular  fibre,  the  interstitial 
tissue  of  which  becomes  filled  with  round  cells  which  ultimately  form  a 
connective  tissue,  and  this  connective  tissue  by  its  hardehing  and  con- 
solidation finally  causes  the  complete  destruction  of  the  muscular  element. 
This  is  not  to  be  confounded  with  the  ano-rectal  syphiloma  in  which 


'  On  Phantom  Stricture  and  Other  Obscure  Forms  of  Rectal  Disease.     Amer. 
Joum.  of  the  Med.  Sci.,  Oct.,  1879. 


184 


DISEASES    OF    THE    RECTUM    AND    ANUS. 


there  is  an  actual  deposit  of  large  masses  of  new  material  in  the  rectal 
wall — masses  which  it  may  be  very  difficult  to  distinguish  from  cancer. 

In  these  various  ways  venereal  disease  and  especially  syphilis  may  re- 
sult in  rectal  stricture,  and  this  accounts  for  the  fact  that  in  about  fifty 
per  cent  of  all  cases  of  stricture  there  is  a  syphilitic  history. 

Non-venereal  Rectal  Stricture. — The  non-venereal  strictures  may  be 
classified  as  congenital,  dysenteric,  and  traumatic. 

The  congenital  narrowing  of  the  rectum  which  is  sometimes  seen  has 
been  already  described  in  speaking  of  the  malformations  of  this  part. 
There  is  also  another  form  of  obstruction  of  the  rectal  calibre  which  is 
supposed  to  be  due  to  an  hypertrophy  of  the  folds  of  mucous  membrane 
which  are  normally  present  in  every  one. 


FiQ.  48.— Longitudinal  section  of  stricture  of  the  rectum  at  the  plica  recti  inferior  (Kohl- 
rausch).  o.  Mucous  membrane,  b.  Circular  muscular  layer  entering  into  the  fold  of  the  stricture. 
c,  Cellular  tissue,    d,  Longitudinal  muscular  layer  passing  over  the  stricture. 

Quain,'  under  the  head  of  impaction  of  faeces,  describes  the  case  of  a 
man,  aged  forty  years,  who  died  with  a  large  accumulation  which  was  evi- 
dently due  to  the  presence  of  two  crescent-shaped  shelves  of  mucous  mem- 
brane projecting  into  the  rectum,  one  attached  opposite  the  prostate  and 
the  other  about  four  inches  higher.  Each  of  these  was  more  than  an  inch 
in  breadth,  and  into  each  the  circular  muscular  fibres  fully  entered,  while 
even  the  longitudinal  layer  dipped  slightly  inward  at  their  bases.  -  Kohl- 
rausch  also  describes  an  analogous  case,  in  which  he  made  an  autopsy  on  a 
criminal  Avho  had  been  executed.    (Fig.  48.)    He  found  an  enormous  dila- 


^  Diseases  of  the  Rectum,  London,  1854,  p.  273. 


NON-MALIGNANT   8TRI0TURK    OF   THB   RECTUM.  185 

tation  of  the  rectum  above  the  spot  at  which  he  locates  the  plica  transver- 
salis.  At  that  point  he  discovered  an  undoubted  stricture  which,  from 
its  hardness  and  extent,  he  at  first  considered  cancerous.  It  presented, 
however,  nearly  the  same  anatomical  condition  as  the  one  just  described; 
the  mucous  membrane  was  sound  and  formed  a  considerable  duplicature; 
the  circular  muscular  fibre  entered  into  this  duplicature  and  formed  a  hai"d, 
hypertrophied,  muscular  ring  several  lines  in  thickness.  The  longitudi- 
nal fibres  passed  directly  over  the  affected  spot  in  this  case,  however,  and 
were  not  unusually  thick  or  firm,  and  the  space  left  between  the  outer 
and  inner  muscular  layers  by  the  bending  inward  of  the  latter  was  filled 
with  connective  tissue.  A  stricture  was  in  this  way  formed  without 
degeneration  of  the  mucous  membrane — a  condition,  however,  which  led 
to  no  less  serious  results.  Such  a  state  furnishes  in  itself  the  ground  for 
constant  aggravation,  for  the  longitudinal  fibres  passing  entirely  over  the 
fold  must,  by  each  contraction  and  by  the  necessary  increase  in  their 
normal  function,  augment  the  substance  of  the  fold  more  and  more,  and 
thus  decrease  the  lumen  of  the  gut.  N^laton,  indeed,  has  written  that 
valvular  retractions  of  the  rectum  are  most  often  only  an  hypertrophy  of  his 
superior  sphincter,  and  that  the  projection  formed  by  it  into  the  cavity 
of  the  intestine  is  the  point  at  which  foreign  bodies  are  most  frequently 
arrested,  as  well  as  that  at  which  invaginations  in  young  children  gener- 
ally begin;  and  in  all  these  points  he  is  borne  out  by  Velpeau.-  Sappey* 
says  **  at  the  level  of  this  band  most  of  the  organic  contractions  of  the 
rectum  are  situated;  its  study,  therefore,  offers  no  less  interest  in  a  patho- 
logical than  in  a  physiological  stand-point.''  This  idea  of  the  pathological 
relations  of  the  mucous  folds  and  muscular  bands  in  the  causation  of  organic 
strictures  may  be  traced  through  the  works  of  Arnold,  Tanchou,  Hyrtl, 
and  Houston;  and  has  its  foundation  in  the  fact  that,  as  these  folds  are 
the  most  subject  to  injuries,  so  they  may  be  the  most  frequent  starting- 
point  of  those  contractions  of  the  rectum  whicli  are  due  to  injuries,  espe- 
cially those  from  foreign  bodies  introduced  ^er  anum  or  swallowed,  and 
from  masses  of  hardened  faeces,  intestinal  concretions,  etc. 

Dysenteric  stricture  and  ulceration  have  also  been  already  described. 
Stricture  due  to  this  cause  is,  perhaps,  more  often  multiple  than  when 
due  to  any  other. 

The  last  cause  to  be  enumerated  is  the  simple  traumatism  which 
may  result  in  stricture,  either  by  causing  ulceration  and  cicatrization  or 
by  exciting  a  chronic  inflammation  in  the  submucous  connective  tissue. 
Amongst  these  traumatisms  may  be  enumerated  operations  upon  haemor- 
rhoids, applications  of  strong  acids,  the  performance  of  some  surgical 
operations,  foreign  bodies,  kicks  and  falls,  and  the  injury  produced  by 
the  head  of  the  child  at  birth. 


'  Velpeau,  Anat.  Chir.,  3d  ed.,  1837,  p.  xxxix. 
»Anat.  Descript..  t.  iv..  p.  222. 


186  DISEASES    OF    THE    RECTUM    AND    ANUS. 

Patliologicdl  Anatomy. — In  studying  the  pathological  anatomy  of 
stricture,  there  are  several  points  to  be  observed,  for  changes  will  be 
found  not  only  at  the  stricture  itself,  but  both  above  and  below  it,  and  in 
the  surrounding  parts. 

From  what  has  been  said  already,  it  will  be  inferred  that  a  stricture 
which  is  not  the  direct  result  of  a  deposit  of  new  material  in  the  rectal 
wall  will  be  composed  either  of  cicatrical  tissue,  such  as  is  found  in  other 
parts  of  the  body,  or  else  of  connective  tissue  which  is  firm  and  dense, 
and  creaks  under  the  knife  on  section.  All  the  connective  tissue  in  the  rec- 
tum at  the  diseased  point,  whether  submucous,  subperitoneal,  or  intermus- 
cular, will  be  found  to  have  increased  in  quantity;  and  this  accounts  for 
the  increased  thickness  of  the  rectal  wall.  The  mucous  membrane  at 
the  seat  of  stricture  will  generally  be  found  destroyed,  and  replaced  by 
granulation  tissue  on  this  fibrous  base,  which  bleeds  easily  when  scraped. 

Above  the  constriction  a  process  occurs  which  will  be  found  to  be 
almost  constant.  This  begins  by  a  dilatation  of  the  bowel  and  an  hyper- 
trophy of  the  muscular  layer,  with,  at  first,  a  thickening  of  the  mucous 
membrane.  Later,  the  mucous  membrane,  due,  probably,  to  the  irrita- 
tion of  retained  faeces,  will  show  all  the  stages  of  ulceration,  from  simple 
congestion  in  some  points  to  a  complete  destruction  in  others,  and  an 
exposure  of  the  muscular  tissue  beneath.  This  ulcerative  process  may 
extend  for  several  inches  up  the  bowel.  The  wall  of  the  bowel  above 
the  stricture  may  be  as  thin  as  paper  in  spots,  and  at  such  points  perfora- 
tion is  apt  to  take  place.  In  a  case  reported  by  Goodhart, '  the  changes 
of  which  we  are  speaking  had  gone  on  to  actual  gangrene,  extending  in 
spots  along  the  transverse  and  descending  colon,  and  were  undoubtedly 
due  to  the  intensity  of  the  inflammatory  action  caused  by  the  retained 
irritant  matters.  Tlie  bowel  is  also  generally  distended  with  gas  and 
faeces,  and  the  latter  are  more  often  fluid  than  solid,  though  fsecal 
tumors,  with  their  well-known  characteristics,  will  sometimes  be  met. 

The  dilatation  above  tlie  stricture  may  reach  an  enormous  size,  and 
may  ultimately  result  in  a  cul-de-sac  or  pouch  which  will  fill  a  large  por- 
tion of  the  abdomen,  and  dip  down  below  the  point  of  constriction,  and 
an  ulceration  in  this  pouch  may  result  in  its  perforation  and  the  estab- 
lishment of  a  fistulous  outlet  for  the  faeces.  Such  an  opening  may  be 
into  the  rectum,  eitlier  above  or  below  the  stricture,  or  into  the  ischio- 
rectal fossa,  with  the  necessary  result  of  abscess.  An  opening  may  also 
be  made  into  the  bladder  in  either  sex,  and  in  females,  into  any  part  of 
the  genital  tract. 

As  showing  what  efforts  nature  is  capable  of  making  to  overcome  the 
occlusion  caused  by  stricture,  the  following  account  of  the  post-mortem 
appearances  found  in  the  body  of  Talma,  the  tragedian,  is  of  great  in- 
terest.    The  whole  history  of  the  case  may  be  found  in  Quain." 

»  Med.  Times  and  Gaz.,  Feb.  28th,  1880. 
«  Op.  cit.,  p.  190. 


NON-M ALIGN AJrr   8TRI0TUEE    OF   THE    RECTUM.  187 

In  the  examination  of  the  body  the  intestines  were  all  found  largely 
"listended  with  air  and  faecal  matter.  .  .  .  The  pelvis  was  filled  with  an 
vnorraous  sac — the  upper  part  of  the  rectum  largely  dilated.  "When  the 
.<ac  was  raised  a  circular  narrowing  of  the  gut  was  discovered.  This  was 
the  stricture.  It  was  at  the  distance  of  six  inches  from  the  anus,  and 
proved,  upon  close  examination,  to  be  wholly  impervious.  It  was,  in 
fact,  a  solid  fibrous  cord,  but  on  the  surface  irregular,  and  having  the 
appearance  of  a  purse,  drawn  tightly  and  puckered,  with  the  strings  tied 
around  it.  The  great  dilatation  of  the  bowel  at  its  lower  end,  dipped 
down  below  the  level  of  the  stricture  in  the  form  of  a  dependent  sac,  in 
which  was  an  opening  about  an  inch  in  diameter,  and  from  this  opening 
issued  a  fluid,  the  same  as  that  diffused  through  the  abdomen.  The  rec- 
tum below  the  stricture  was  no  more  than  the  size  of  a  child's  intestine, 
and  upon  it,  close  to  the  stricture,  was  an  ulcerated  surface  with  a  nar- 
row ojiening,  to  which  the  edges  of  the  aperture  above  the  stricture  had 
been  adherent.  A  new  communication,  but  an  imperfect  one,  had  thus 
been  established  between  the  two  parts  of  the  gut — severed  one  from  the 
other  by  the  stricture.  But  the  connection  had  given  way,  doubtless  in 
consequence  of  the  violence  of  the  expulsive  efforts,  and  thus  the  con- 
tents of  the  bowel  had  escaped  a  short  time  before  death. 

The  cellular  tissue  in  the  ischio-rectal  fossae  around  a  stricture  may 
also  become  hard  and  lardacous,  as  a  result  of  chronic  inflammation  ;  and 
this  change  may  extend  to  some  distance  from  the  original  starting-point 
along  the  sacrum,  as  high  as  the  promontory,  and  into  the  subperitoneal 
tissue  of  the  iliac  fossae. 

Abscess  is  always  liable  to  occur  in  the  neighborhood  of  the  stricture, 
probably  from  lowered  vitality  in  the  parts,  and  this  accounts  for  the  rel- 
ative frequency  of  fistulae  in  this  disease.  These  may  be  both  numerous 
and  extensive,  and  may  make  communications  between  the  rectum  and 
any  of  the  adjacent  organs.  For  this  reason  a  fistula  should  always  lead 
the  surgeon  to  think  of  stricture  and  to  examine  for  it. 

Allingham  has  also  called  attention  to  the  frequent  existence  of  a  low 
form  of  peritonitis  in  connection  with  stricture,  an  inflammation  marked 
by  tympanites,  vomiting,  and  pain,  especially  on  walking  or  moving,  and 
attended  by  thickening  of  the  peritoneum  and  old  and  recent  adhesions. 

Below  the  stricture  the  rectum  may  sometimes  be  found  unchanged 
from  its  normal  condition,  but  it  will  generally  be  ulcerated  as  it  is  above, 
or  else  there  will  be  haemorrhoidal  tumors,  excoriations,  and  vegetations 
and  condylomatous  tags  of  larger  or  smaller  size.  These  condylomatous 
growths  are  the  result  simply  of  irritation  of  the  discharge  from  the  pro- 
cess above. 

Most  strictures  are  located  in  the  lower  part  of  the  rectum,  and  hence 
their  presence  is  easily  detected  in  the  majority  of  cases.  They  are  far 
more  frequent  in  females  than  in  males,  because  many  of  the  causes  which 
produce  them  operate  chiefly  in  females.     Age  has  little  influence  upon 


188  DISEASES   OF   THE   EECTUM    AND    ANUS. 

their  frequency  after  the  period  of  adult  life.  A  stricture  may  or  may 
not  involve  the  whole  circumference  of  the  bowel;  and  the  contraction 
may  be  so  slight  as  not  to  be  apparent  till  the  bowel  is  distended  with  the 
speculum,  when  a  falciform  band  may  spring  out  from  one  side.  In 
more  extensive  disease,  there  is  still  usually  a  passage  for  the  faeces,  but 
this  may  be  very  slight.  The  most  extensive  disease  will  be  found  to  be 
due  generally  either  to  syphilitic  deposit,  syphilitic  sclerosis,  or  dysen- 
tery; and  in  such  cases  the  calibre  of  the  bowel  may  be  lessened  for  a 
space  of  several  inches. 

Symptoms. — "Where  stricture  is  the  result  of  ulceration,  the  signs  of 
ulceration  will  at  first  mask  those  of  the  stricture,  and  the  patient  will 
complain  of  pain,  discharge  from  the  anus,  excoriations,  and  warty 
growths,  together  with  the  failure  of  the  general  health,  gastric  and  in- 
testinal disturbance,  and  wandering  pains. 

The  one  sign  of  a  stricture  is  the  obstruction,  and  this  may  show 
itself  in  several  ways,  generally  at  first  by  alternate  attacks  of  constipa- 
tion and  diarrhoea.  The  constipation  is  mechanical,  and  is  due  to  the 
accumulation  of  fasces  above  the  constriction.  The  diarrhoea  is  secondary 
to  the  accumulation,  which,  in  time,  begins  to  act  as  a  foreign  body,  set- 
ting up  a  catarrhal  inflammation,  as  a  result  of  which  sufficient  fluid  is 
poured  into  the  bowel  to  soften  the  hardened  mass,  and  large  quantities 
are  discharged,  only  to  be  followed  by  a  fresh  accumulation. 

It  has  often  been  asserted  that  a  well-marked  lessening  of  the  rectal 
calibre  must,  in  the  nature  of  things,  produce  a  change  in  the  shape  of 
the  faeces,  but  this  is  not  quite  true.  The  flattened,  tape-like  stool  is  a 
sign  of  value  when  present,  and  should  always  lead  to  careful  exploration, 
but  it  may  not  be  present  even  in  the  worst  cases  of  stricture,  and  it  may 
exist  Avithout  stricture;  in  the  latter  case  generally  being  due  to  an  irreg- 
ular spasmodic  action  of  the  sphincters,  or  to  pressure  from  without  the 
bowel.  This  point,  to  which  attention  was  called  by  "White  '  as  long  ago 
as  1815,  has  again  recently  been  made  the  subject  of  discussion.  In  an 
able  article  on  "  Annular  Stricture  of  the  Intestine;  its  Diagnosis  and 
Treatment,"  in  the  British  Medical  Journal  for  May  31st,  1879,  Mr. 
Stephen  Mackenzie  wrote:  '"The  fact  that  full-sized,  properly  formed 
faeces  are  occasionally  passed,  of  course  shows   that  there  can  be  no 

'  ' '  With  regard  to  the  lessened  diameter  of  the  faeces,  just  noticed,  which  must 
necessarily  be  the  case  whenever  a  permanently  contracted  state  of  the  gut  takes 
place;  yet  it  has  happened  in  some  instances  where  that  change  had  been  ob- 
served, that,  in  a  more  advanced  period  of  the  disease,  faeces  of  a  natural  size 
had  occasionally  passed.  The  knowledge  of  this  circumstance  I  consider  of  some 
importance,  inasmuch  as,  if  properly  attended  to,  it  will  prevent  the  practitioner 
from  hastily  concluding  there  is  no  stricture  merely  from  an  examination  of  the 
evacuations,  when  symptoms  may  otherwise  indicate  the  presence  of  the  disease." 
— ' '  Obser%-ations  on  Stricture  and  other  Affections  occasioning  a  Contraction  in 
the  Lower  Part  of  the  Intestinal  Canal,  etc.,"  Bath,  1815. 


NON-MAUGNANT    STRICTURE   OF   THE   RECTUM.  189 

organic  Stricture. "  Under  criticism,  he  withdrew  the  statement  in  the 
issue  of  the  sumo  journal  for  May  15th,  1880,  with  the  explanation  that 
it  was  founded  ou  his  personal  observation,  which  had  since  been  supple- 
mented and  corrected  by  that  of  others. 

In  a  case  which  I  recently  saw  in  consultation  with  Dr.  De  Long,  of 
Brooklyn,  I  had  a  long-wished-for  opportunity  to  observe,  in  the  presence 
of  a  number  of  physicians,  the  actual  mechanism  by  which  tape-like 
stools  are  produced.  The  woman  suffered  from  a  stricture  one  inch 
above  the  anus,  which  was  of  sufficient  calibre  to  admit  the  ends  of  two 
fingers  easily.  She  had  never  noticed  any  deformity  of  the  faeces. 
"While  under  the  influence  of  ether,  and  after  the  sphincter  had  been  very 
thoroughly  dilated,  an  O'Beirne's  tube  was  passed  through  the  rectum, 
which  was  empty,  into  the  sigmoid  flexure,  which  was  full.  After  rest- 
ing there  a  few  moments,  it  provoked  a  movement  of  the  bowels.  The 
stricture  was  instantly  crowded  down  into  view,  appearing  at  the  anus, 
and  taking  the  place  of  the  anus,  which,  owing  to  the  complete  dilata- 
tion, ceased  to  have  any  action,  and  was  simply  a  patulous  ring.  Through 
the  stricture  there  came  a  long,  tape-like  evacuation,  the  mould  which 
gave  it  its  peculiar  form  being  the  stricture  pressed  to  the  surface  of  the 
perineum,  and  greatly  lessened  in  calibre  by  folds  of  mucous  membrane, 
which  were  crowded  into  it  from  above.  While  remarking  to  those  pres- 
ent on  the  peculiar  mechanism  of  its  production,  the  straining  ceased, 
the  stricture  rose,  the  mucous  membrane  was  relaxed,  and  a  passage  of 
natural  formation  was  the  result.  This  alternation  was  repeated  several 
times.  At  etich  violent  effort  the  stricture  was  forced  down  to  the  anus, 
the  membrane  above  it  was  crowded  into  it  so  as  to  greatly  lessen  its  cali- 
bre, and  a  flat  passage  was  the  result.  When  the  effort  was  less  violent, 
there  was  still  a  passage,  but  the  stricture  having  risen  to  its  place,  and 
not  being  so  tightly  filled  with  the  mucous  membrane,  the  passage  was 
natural.  The  lesson  to  my  own  mind  was  this:  that  a  stricture  of  large 
calibre  might,  as  a  result  of  straining,  cause  a  passage  of  very  small  size; 
and  that,  to  get  this  peculiar  shape,  the  stricture  must  be  crowded  down 
so  as  to  actually  take  the  place  of  the  external  sphincter,  and  be  the  last 
contracted  orifice  through  which  the  soft  substance  is  expressed.  It  is 
well  known  that,  with  the  closest  stricture  high  up,  the  faeces  may  be  re- 
formed in  the  rectum  below,  and  be  passed  normal  in  size.  At  the  bed- 
side but  little  importance  is  to  be  attached  to  the  statements  of  patients 
concerning  this  matter. 

After  a  stricture  has  existed  for  a  certain  length  of  time,  signs  of  ob- 
struction will  be  manifest  by  abdominal  ])alpation  and  inspection.  The 
transverse  and  descending  colon  can  be  felt  partially  distended  with 
masses  of  faeces,  and  will  bo  dull  ou  percussion,  tender  to  the  touch, 
somewhat  movable,  and  pitting  on  firm  pressure.  After  an  attack  of 
diarrhoea,  or  after  a  brisk  purge,  these  accumulations  may  disappear, 
only  to  form  again  in  a  short  time.     Generally  complete  obstruction  does 


190  DISEASES    OF    THE    RECTUM    AND    AinJS. 

not  occur  without  ample  warning  in  this  way.  It  is  preceded  by  eructa- 
tions of  fetid  gas,  the  abdomen  swells  and  becomes  very  tender  on  pres- 
sure, the  coils  of  intestine  are  visible  througli  the  abdominal  wall,  and 
their  visibly  violent  peristalsis  gives  proof  of  the  effort  nature  is  making 
to  overcome  the  obstacle.  After  a  short  time  the  patient  is  exhausted, 
and,  unless  surgical  aid  is  given,  dies.  Complete  obstruction  has  been 
seen  to  occur  very  suddenly,  forming  almost  the  first  intimation  of  seri- 
ous disease;  and  this  is  more  apt  to  be  the  case  where  the  stricture  is  high 
up  in  the  rectum  or  at  the  Junction  with  the  sigmoid  flexure.  It  comes 
on  with  the  usual  signs  of  acute  intestinal  strangulation — pain,  swelling 
of  the  abdomen,  bloody  passages,  etc.,  and  it  may  be  caused  by  some  in- 
digestible substance  which  has  been  swallowed  and  refuses  to  pass  the 
stricture,  or  merely  by  hardened  fasces  or  prolapse  of  the  bowel  above  into 
the  constriction.     The  following  case  is  one  of  quite  a  large  class: 

"  The  patient,  a  middle-aged  woman,  was  admitted  into  St.  Bartho- 
lomew's Hospital  with  symptoms  of  sudden  obstruction.  She  stated  that 
she  had  enjoyed  good  health  up  to  the  onset  of  the  attack,  nor  had  she 
previously  been  troubled  with  constipation.  The  attack  commenced  sud- 
denly while  at  work,  and  was  followed  by  obstinate  vomiting  and  consti- 
pation. The  symptoms  having  existed  for  some  days,  and  the  case 
appearing  urgent,  while  the  sudden  onset  of  the  symptoms  suggested 
mechanical  strangulation,  it  was  deemed  advisable  to  open  the  abdominal 
cavity.  This  being  done,  Mr.  Marsh  felt  a  hard  cancerous  mass  in  the 
walls  of  the  bowel,  which  caused  the  obstruction.  The  bowel  was  opened 
above  the  obstruction,  stitched  to  the  sides  of  the  wound,  the  patient 
making  a  good  recovery.' 

There  is  one  important  element  in  the  obstruction  due  to  stricture, 
which  must  not  be  forgotten.  It  will  sometimes  happen  that  fatal  ob- 
struction will  occur  even  when,  on  post-mortem  examination,  the  calibre 
of  the  stricture  is  found  -to  be  large  enough  to  permit  the  passage  of  the 
finger,  showing  that  the  obstruction  could  not  have  been  due  merely  to 
the  contraction  of  the  new  growth.  John  Hunter  remarked  a  fact  of 
this  sort,  as  is  pi'oved  by  the  following  account: 

"On  introducing  the  pipe  by  the  anus,  it  was  found  to  come  butt 
against  one  side  of  the  upper  part  of  the  cavity  of  the  tumor,  where  there 
was  a  bend  in  the  passage;  but  why  a  crooked  pipe  did  not  pass  when 
attempted  to  be  passed  by  turning  it  to  all  sides,  I  cannot  conceive,  or, 
why  a  bougie  which  was  slightly  bent  did  not  hit  the  hole,  is  not  easily 
accounted  for;  but,  what  is  more  extraordinary  than  either,  why  a  clyster 
did  not  pass  freely  up;  or  why  did  not  the  wind  or  soft  excrementitious 
matter  that  did  yet  lay  [sic]  pass  readily  down,  while  I  could  pretty 
readily  pass  the  end  of  my  finger  down  from  the  gut  above  into  the 


'  Cripps,  Cancer  of  the  Rectum,  p.  107. 


NON-MAUONANT    8TRI0TDEE   OF   THE    KECTUM.  191 

tumor?    The  folds  of  the  contracted  part  did  not  appear  after  death  to 
have  been  sufficient  fornn  entire  stoppage  of  this  sort."' 

Notwithstanding  the  statement  that  the  folds  of  the  part  did  not 
appear  after  death  to  have  been  suflBcient  to  produce  the  stoppage,  it 
seems  that  a  prolapsed  fold  of  mucous  membrane  is  the  only  thing  likely 
to  give  rise  to  it.  In  cases  of  advanced  disease  a  spasmodic  stricture  (if 
such  ever  occurs)  would  seem  out  of  tlie  question,  whereas  partial  or 
complete  invagination  in  this  part  is  known  to  be  of  frequent  occurrence. 
As  shown  by  Rokitausky,"  the  paralysis  above  the  stricture  is  also  an  un- 
doubted element  in  the  production  of  the  occlusion. 

Diagnosis. — The  first  means  of  diagnosis  in  stricture  is  the  examina- 
tion with  the  finger,  and  as  the  great  majority  of  strictures  are  confined 
to  the  lower  portion  of  the  rectum  this  is  in  itself  generally  suflBcient.  It 
is  the  best  and  safest  and  least  painful  of  all  the  means  of  diagnosis  when 
properly  executed,  and  yet  it  may  be  the  immediate  cause  of  death  to  the 
patient  when  roughly  practised.  There  is  an  inborn  tendency  on  the 
part  of  many,  when  the  index  finger  comes  in  contact  with  a  tight  stric- 
ture, to  bore  through  the  narrow  passage  which  is  left  and  feel  what  is  on 
the  other  side — a  tendency  to  be  struggled  against  and  overcome.  If  the 
surgeon  has  deliberately  determined  to  practise  divulsion,  this  is  one  way 
to  do  it,  but  at  present  we  are  speaking  of  diagnosis,  and  forcible  dilata- 
tion is  not  diagnosis,  but  a  very  grave  surgical  procedure.  The  finger 
should  therefore  be  passed  slowly  up  to  the  stricture,  and  unless  the  cali- 
bre atimits  of  it  without  straining,  it  should  not  be  passed  further.  The 
condition  of  the  parts  below  may  also  be  appreciated,  the  amount  of  in- 
duration estimated,  and  a  general  idea  formed  of  the  nature  and  extent 
of  the  disease.  In  women  the  vaginal  touch  will  generally  be  found  of 
the  greatest  value  and  should  never  be  omitted. 

As  a  rule  all  can  be  learned  in  this  way  that  can  be  learned  in  any 
other  where  the  disease  is  within  reach  of  the  finger,  and  nothing  is  to 
be  gained  by  a  painful  speculum  examination  or  the  use  of  the  bougie — 
means  of  diagnosis  which,  however  valuable  where  the  stricture  cannot  be 
felt  by  the  finger,  are  of  little  use  for  the  lower  four  inches  of  the  rectum. 

When  a  stricture  is  situated  high  up  in  the  rectum  or  in  the  sigmoid 
flexure,  the  confidence  in  diagnosis  which  comes  from  actual  contact  of 
the  finger  with  the  dise:ise  is  entirely  lost,  and  there  is  perhaps  nothing 
in  the  whole  range  of  surgic41  diagnosis  which  requires  more  skill  than 
the  detection  of  stricture  in  this  part,  and  nothing  attended  with  more 
U!icertainty.  The  symptoms  of  stricture  of  the  upper  part  of  tlie  rectum 
are  not  the  same  as  when  the  disease  is  lower  down,  for  the  nerve-supply 
is  not  the  same,  nor  is  tlie  sphincter  muscle  involved.     For  this  reason 


'  Hunterian  MS.    Cases  and  Dissections,  No.  59,  in  "  Descriptive  Catalogue," 
etc.,  vol.  iii.,  p.  98.     From  Mayo,  op.  cit.,  p.  249. 

■  •'  Manual  of  Path,  Anat.,"  vol.  ii.,  translated  by  Sieveking. 


192  DISEASES    OF    THE    RECTUM    AND    ANUS. 

the  patient  is  much  more  apt  to  suppose  himself  suffering  from  chronic 
constipation  and  dyspepsia  than  from  haemorrhoids.  Pain  in  the  abdo- 
men, not  always  localized  at  the  left  side,  pain  in  the  loins  and  down  the 
legs,  obstinate  constipation  and  occasional  diarrhoea,  are  the  things  usu- 
ally complained  of,  and  in  these  there  is  nothing  upon  which  to  base  a 
positive  diagnosis.  The  faeces  may  never  present  any  jieculiarity,  for  the 
reason  that  they  are  accumulated  in  the  rectal  pouch  below  the  obstruc- 
tion and  passed  in  the  natural  shape.  They  are  apt  to  be  lumpy  and 
unformed  rather  than  misformed,  but  they  may  be  streaked  with  blood 
or  slime  which  is  always  a  valuable  sign  and  one  calling  for  careful  phy- 
sical exploration. 

A  stricture  in  the  locality  in  question  must  be  examined  for  with  the 
greatest  care  and  gentleness,  and  the  examination  will  often  be  negative 
in  its  results.  The  attempt  to  decide  the  question  by  the  use  of  bougies 
is  altogether  unsatisfactory  and  by  no  means  free  from  danger.  It  is 
unsatisfactory  because  an  obstruction  will  generally  be  encountered  in 
trying  to  pass  an  instrument  of  any  considerable  size  through  this  part  of 
the  bowel,  and  the  passage  of  an  instrument  of  small  size,  which  is  much 
easier,  proves  nothing.  It  is  dangerous  because,  with  the  ordinary  rub- 
ber rectal  bougies,  a  diseased  bowel  may  easily  be  ruptured  with  what  may 
seem  to  the  operator  to  be  no  more  force  than  is  justified  in  attempting 
to  overcome  the  natural  obstructions  to  this  part  of  the  passage.  The 
bulbous-pointed  bougie  on  the  flexible  stem  appears  a  priori  to  be  the 
most  suitable  for  the  exploration,  but  it  has  two  objectionable  features. 
It  is  not  at  all  an  easy  instrument  to  pass,  and  if  passed  through  an  ob- 
struction too  much  force  is  required  for  its  withdrawal  after  the  abrupt 
shoulder  is  in  contact  with  the  stricture. 

O'Beirne  gives  the  following  description  of  the  way  to  pass  his  tube: 
*' A  gum-elastic  catheter  of  the  largest  size  was  inserted  into  the  anus, 
and  passed  to  the  height  of  about  two  inches  up  the  rectum,  where  its 
further  progress  was  felt  to  be  opposed  by  strong  expulsive  efforts,  which 
lasted  but  a  few  seconds,  then  relaxed  and  again  became  renewed.  By 
first  yielding  somewhat  to  these  efforts,  and  then  taking  advantage  of  the 
succeeding  relaxation,  the  instrument  was  gradually  passed  to  the  height 
of  seven  or  eight  inches.  At  this  point  the  resistance  was  sensibly  felt 
to  be  much  greater  than  at  any  former,  but,  instead  of  allowing  it  to 
yield,  the  instrument  was  pressed  more  firmly  upward.  Having  steadily 
continued  this  pressure  for  about  one  minute,  the  resistance  suddenly 
gave  way,  the  tube  passed  upward  as  if  through  a  narrow  ring,"  etc. 

Even  with  the  softest  instrument,  the  moment  when  the  obstruction 
suddenly  gives  way,  and  the  instrument  passes  forward,  will  be  an  anxious 
one  for  the  surgeon,  and  the  life  of  the  patient  may  be  sacrificed  to  desire 
for  certanity  of  diagnosis. 

A  bougie  intended  for  this  purpose  should  always  be  hollow  and  the 
opening  at  the  lower  end  should  be  of  a  size  to  admit  the  small  tube  of  a 


NON-ITALIONANT   STRICTURE   OF  THE   RECTUM.  193 

Davidson's  syringe  which  should  be  fitted  to  it  before  the  attempt  to  pass 
it  is  begun.  Then  with  a  basin  of  warm  water  close  at  hand  the  bougie 
may  be  introduced  and  at  the  first  obstruction  the  bowel  should  be  filled 
with  water  until  it  is  moderately  distended.  In  this  way  the  folds  of 
mucous  membrane  are  drawn  out  of  the  way  by  the  distention  of  the 
wliole  bowel  and  one  great  obstacle  is  eliminated.  The  next  is  the  pro- 
montory of  the  sacrum  which  is  much  more  easily  passed  by  a  soft  than 
by  a  stiff  instrument.  Without  these  precautions,  and  sometimes  with 
them,  the  inexperienced  examiner  will  find  a  stricture  in  the  rectum  of 
nineteen  persons  out  of  twenty,  no  matter  how  healthy  they  may  be;  and 
for  this  reason  it  is  seldom  safe  to  rest  the  diagnosis  of  stricture  on  the 
fact  that  a  bougie  cannot  be  made  to  pass.  Moreover  a  bougie  of  good 
size  will  often  pass  a  stricture  small  enough  to  produce  great  trouble. 

In  certain  cases  information  may  be  gained  by  the  use  of  a  long  cylin- 
drical speculum  with  the  patient  bending  over  the  table  or  chair  and 
straining  down  to  bring  the  parts  into  view.  Fortunately,  however,  we 
are  not  limited  to  either  of  these  means  for  a  diagnosis,  for,  if  the  stric- 
ture be  cancerous  and  of  any  size  the  mass  may  be  felt  through  the  abdo- 
minal wall  by  careful  palpation;  and  if  not,  and  the  symptoms  wan'ant 
it,  thp  sphincter  may  be  stretched  or  incised  sufficiently  to  allow  of  in- 
troducing the  hand  into  the  rectal  pouch.  Passing  the  whole  hand  into 
the  rectal  pouch,  and  then  the  finger  into  the  sigmoid  flexure  as  far  as 
possible,  is  a  very  different  affair  from  trying  to  pass  tlie  whole  hand  into 
the  flexure,  and  is  free  from  danger,  because  the  distention  by  the  hand 
IS  not  carried  to  the  point  where  danger  is  located  at  the  reflection  of  the 
peritoneum.  Though  seemingly  a  much  more  serious  matter,  it  is  really 
safer  than  any  forcible  use  of  the  bougies,  and  by  it  the  diagnosis  maybe 
rendered  certain  for  all  tliat  part  of  the  bowel  at  present  under  consider- 
ation. I  know  of  no  other  way  than  this  by  which  a  stricture  in  the  sig- 
moid flexure  which  cannot  be  felt  by  external  manipulation  can  certainly 
be  recognized. 

Treatment. — The  treatment  of  stricture  of  the  rectum  is  both  constitu- 
tional and  local,  medicinal  and  operative.  The  first  question  to  be  answered 
is  as  to  the  advisability  of  anti-syphilitic  medication.  In  recent  cases 
where  syphilis  is  to  be  suspected  this  should  never  be  omitted. 

It  is  well  to  exercise  caution  in  this  matter,  however,  and  the  cases  in 
which  the  patient  should  be  submitted  to  this  form  of  treatment  should  be 
carefully  chosen.  The  practitioner  who  considers  the  majority  of  stric- 
tures as  syphilitic  and  indiscriminately  uses  mercury  and  iodide  of  potasli 
will  be  mistaken  about  as  often  as  he  who  looks  upon  most  of  his  cases  as 
cancerous  and  therefore  incurable.  The  general  condition  of  a  patient 
with  a  stricture  is  never  up  to  normal,  and  an  unnecessary  course  of  medi- 
cation may  do  great  harm  instead  of  good. 

Cicatricial  tissue,  though  the  result  of  specific  disease,  is  beyond  the 
reach  of  specific  treatment,  but  where  the  case  can  be  seen  early  enough, 
13 


194  DISEASES    OF   THE   RECTUM    AND    ANUS. 

much  improvement  can  be  gained  by  a  thorough  course  of  mixed  treat, 
ment  and  a  gummatous  deposit  or  a  syphilitic  sclerosis  may  be  checked. 
Mercury  and  iodide  of  potash  should  both  be  given,  neither  being  relied 
upon  alone.  Mercury  in  the  form  of  an  oinment  or  the  oleate  mav 
also  be  administered  by  the  rectum,  and  the  full  constitutional  effects  of 
the  drug  may  be  gained  in  a  very  short  time  by  this  method;  it  is,  how- 
ever, an  irritating  application  and  in  cases  of  much  ulceration  and  sensi- 
tiveness it  may  not  be  well  borne. 

M.  Trelat'  has  seen  good  effects  follow  internal  medication  in  cases 
of  ano-rectal  syphiloma,  thougli  Fournier  speaks  so  positively  as  to  their 
uselessness.  He  gives  two  cases  in  which  the  disease  was  of  long  stand- 
ing, but  yielded  to  a  considerable  degree  to  the  use  of  mercury  and  iodide 
of  potash  internally,  with  glycerin  applied  locally.  Van  Buren"  has  also 
seen  good  effects  in  a  case  of  this  kind  from  the  use  of  the  modified  Zitt- 
man's  decoction,  in  mild  doses,  guarded  by  bismuth,  combined  with  in- 
unctions of  the  oleate  of  mercury. 

The  following  case  taken  from  Zappula'  is  worth  reproducing  entire, 
proving  as  it  is  supposed  to  do  that  a  syphilitic  stricture  which  is  so  ex- 
tensive as  to  give  rise  to  the  diagnosis  of  malignant  disease  may  be  made 
to  completely  disappear  by  specific  treatment.  The  author  says;  "The 
patient  who  is  the  subject  of  this  case  is  one  of  my  colleagues  and  an 
intimate  friend,  a  man  thirty-six  years  of  age  and  of  nervous  tempera- 
ment. The  family  history  is  good.  The  patient  has  always  enjoyed 
good  health  with  the  exception  of  some  attacks  of  malaria,  a  gonorrhoea 
contracted  in  1851,  and  some  months  after  an  ulcer  in  the  balano-prepu- 
tial  fold,  which  was  followed  by  a  painful  adenitis  in  the  right  groin 
which,  however,  did  not  suppurate.  The  ulcer  was  of  considerable  size, 
lasted  about  forty  days,  and  ended  by  healing  under  the  influence  of  re- 
peated cauterizations.  Nothing  more  is  known  of  the  character  of  that 
ulceration,  and  it  is  impossible  to  establish  any  connection  between  it  and 
the  disease  under  consideration.  But  it  is  certain  that  the  patient  used 
in  inunctions  more  than  one  hundred  grammes  of  mercurial  ointment, 
and  that  an  examination  of  the  former  site  of  the  ulcer  shows  now  no 
trace  of  its  existence. 

"  The  first  symptom  of  the  present  disease  was  pain  which  started  from 
the  right  side  of  the  anus,  extended  as  far  as  the  tubei'osity  of  the  ischium 
on  the  corresponding  side,  or  sometimes  took  an  opposite  course,  but 
always  was  confined  to  the  ano-rectal  region .  The  pain  was  of  neuralgic 
character,  intermittent,  returning  with  more  or  less  frequency,  but 
always  very  severe  and  accompanied  by  the  phenomena  of  spasm^     Defe- 

'  Le  Progres  Med.,  June  22d,  1878. 

«  On  Phantom  Stricture,  etc.  The  Amer.  Journal  of  the  Medical  Sciences, 
October,  1879. 

^  Annali  universal!  de  Medicina,  vol.  ccxvii.,  p.  137. 


NON-MAIJONANT   8TRICTUPE    OF   THE    RECTUM.  195 

cation  became  a  little  less  frequent,  but  was  painless  except  once  when 
there  was  a  sharp  pain  about  the  anus.  A  fissure  was  suspected,  and 
though  it  was  impossible  to  discover  it,  a  suitable  injection  of  laudanum 
and  rhutany  was  administered. 

"The  pain  disappeared  from  the  ischio-rectal  fossse,  but  symptoms  of 
impaction  followed  which  purgatives  in  large  doses  failed  to  relieve,  and 
which  on  the  contrary  led  to  still  more  alarming  accidents.  It  was  under 
these  circumstances  that  I  first  saw  the  patient  on  the  24th  of  September. 
He  had  suffered  for  one  month  and  his  condition  seemed  to  be  very 
serious.  Three  large  faecal  tumors  occupied  the  left  iliac  fossa,  the  epi- 
gastrium, and  the  right  flank.  Severe  colic  starting  from  the  left  iliac 
fossa  extended  over  the  whole  abdomen  and  reached  to  the  anus.  The 
abdomen  was  swollen  and  painful  to  the  toucii,  and  pain  was  also  caused 
by  pressure  in  the  ano-ischiatic  region  where,  however,  no  trace  of  or- 
ganic disease  could  be  discovered.  An  examination  of  the  anus  led  to 
the  discovery  of  a  stricture  so  tight  that  only  the  end  of  the  little  finger 
could  be  introduced  without  causing  great  pain. 

**  Such  was  tlie  group  of  symptoms  the  patient  presented  when  I  first 
examined  him:  retraction  of  the  anus  and  probably  of  the  rectum;  abso- 
lute necessity  of  causing  the  disappearance  of  the  obstacle  to  the  exit  of 
faeces  and  of  exciting  intestinal  contraction.  But  it  was  impossible  for 
me  to  know  whether  the  contracture  was  due  to  ragades  located  immedi- 
ately within  the  anus,  to  the  neuralgic  symptoms  described  above,  or  to 
some  neoplasm  in  the  lower  part  of  the  rectum.  Nevertheless  I  attacked 
the  symptom  of  contracture  by  the  method  of  Recaraier,  and  it  may  be 
imagined  how  painful  this  proceeding  was  while  the  state  of  the  sufferer 
did  not  permit  me  to  give  ether.  However,  during  the  operation  I  dis- 
covered an  enormous  dilatation  of  the  lower  portion  of  the  rectum  from 
which  escaped  a  considerable  quantity  of  glairy  matter.  Twice  after 
wards  I  administered  large  doses  of  purgatives,  but  the  patient  vomited 
them  almost  immediately,  and  the  abdominal  meteorism  increased. 
Then  the  vomiting  became  spontaneous,  the  fever  increased,  and  the 
symptoms  of  strangulation  became  so  intense  that  the  life  of  the  patient 
seemed  to  me  about  to  be  sacrificed,  when  again,  under  the  influence  of 
two  inunctions  of  croton  oil  on  the  abdomen,  there  followed  a  tumultuous 
expulsion  of  faeces.  More  than  twenty  hard,  round,  faecal  masses  came 
away  and  after  this  relief  all  went  well.  But  the  patient's  ease  only 
lasted  a  few  days,  for  the  faeces  very  soon  accumulated  afresh,  without 
forming  tumors,  liowever;  the  passages  were  made  with  difficulty;  and 
purgatives  administered  from  time  to  time  caused  the  expulsion  of  har- 
dened masses  mixed  with  mucus  and  sometimes  with  blood.  However, 
the  suffering  continued,  and  was  especially  violent  after  tlie  administra- 
tion of  purgatives  even  in  small  doses;  the  abdominal  pain  became  more 
and  more  severe;  the  ischio-rectal  pain,  together  with  the  neuralgia 
which  he  had  at  the  commencement,  returned  and  resisted  the  most  pow- 


196  DISEASES    OF   THE    BECTUM    AND    ANUS. 

erful  local  anodynes;  but  the  anal  spasm  did  not  return.     Tnspitc  cf 
these  frightful  sufferings  there  was  as  yet  little  loss  of  flesh. 

**But  the  organism  could  not  long  withstand  such  sufferings  and  ema- 
ciation supervened;  there  was  fever  at  irregular  intervals  always  preceded 
by  a  chill,  and  a  pale-yellowish  tint  to  the  skin.  An  examination  of  the 
rectum,  which  had  been  delayed  on  account  of  the  repugnance  of  the 
patient,  was  extremely  painful;  but  instead  of  finding  as  before  a  consid- 
erable dilatation  of  the  lower  extremity,  I  found  the  tissues  soft  and 
uneven,  giving  to  the  finger  the  sensation  of  folds  and  anfractuosities,  in 
a  Avay  that  without  a  speculum  examination  would  have  led  one  to  be- 
lieve in  the  existence  of  condylomata  and  extensive  destruction  of  tissue; 
but  by  the  aid  of  that  instrument  I  was  able  to  prove  that  we  had  to  deal 
with  an  hypertrophy  of  the  mucous  membrane  which  was  mammillated. 

**  This  condition  was  found  completely  surrotinding  the  rectum  and 
reaching  as  high  as  the  eye  could  see.  The  sensation  which  my  finger 
experienced  could  not,  therefore,  be  due  to  a  duplicature  of  the  hyper- 
trophied  mucous  membrane.  A  sound  introduced  into  the  rectum  passed 
freely  eleven  centimetres,  but,  arrived  at  that  point,  it  was  arrested  by  an 
insurmountable  obstacle,  and  caused  great  pain.  A  second  examination 
practised  about  a  fortnight  later  permitted  me  to  observe  a  small  tumor 
on  the  right  side  of  the  intestine  four  centimetres  above  the  anus.  This 
tumor  was  the  size  of  a  hazel-nut,  spherical,  smooth,  somewhat  elastic, 
and  indolent  even  to  pressure.  It  was  absolutely  immovable  and  did  not 
seem  adherent  to  the  mucous  membrane  beneath  which  it  lay.  But  all 
these  details  were  very  difficult  to  appreciate  well  on  account  of  the  hy- 
pertrophy of  the  mucous  membrane  and  the  irregularities  of  its  sur- 
face. 

"The  retraction  of  the  rectum  was  then  an  evident  fact,  revealed  not 
only  by  the  rational  symptoms,  but  by  the  physical  examination  and  the 
hypertrophic  thickening  of  the  mucous  membrane.  But  the  diagnosis 
of  the  nature  of  the  constriction  still  remained  doubtful,  for  the  data  fur- 
nished by  direct  examination  seemed  insufficient.  We  were  therefore  re- 
duced to  making  a  diagnosis  by  exclusion,  and  rejecting  successively  the 
valves  of  mucous  membrane,  strictures  due  to  ulceration  or  simple  in- 
flammation, excluding  also  the  idea  of  a  spasmodic  or  venereal  stricture, 
tubercular  stricture,  polypus,  and  haemorrhoids,  we  were  naturally  led  to 
the  conclusion  that  we  were  dealing  with  a  cancer.  However,  we  had 
no  pathognomonic  sign  on  which  to  base  this  diagnosis;  and  the  origin 
and  evolution  of  the  disease  were  not  those  of  cancer,  the  march  of  Avhich 
is  slow  and  rarely  takes  such  an  exceptionally  rapid  course.  Thus, 
hesitating  to  admit  a  cancer,  I  thought  of  syphilis.  But  it  was  neces- 
sary to  know  for  certain  whether  our  patient  was  suffering  from  syphilis. 
It  was  necessary  to  be  able  to  establish  by  well-observed  facts  that  a 
syphilis  may  remain  latent  nearly  nineteen  years  without  causing  any 
species  of  manifestation.     The  emaciation,  the  coloration  of  the  skin. 


NON-MALIGNANT   STRICTURE    OF   THE    RECTUM.  197 

the  daily  fever,  all  seemed  to  indicate  the  presence  of  cancer,  and  to  ex- 
clude the  idea  of  syphilis. 

*'  However,  the  powerlessness  of  art  in  the  presence  of  a  hetero- 
plastic lesion  determined  me  to  attempt  an  antisyphilitic  treatment 
which  I  commenced  by  administering  large  doses  of  iodide  of  potash. 
After  twelve  days  of  this  treatment,  the  patient  experienced  relief  of  all 
the  worst  symptoms.  The  first  to  yield  was  the  ischio-anal  pain  which 
for  some  time  had  been  exceedingly  severe.  The  anal  tumor  diminished 
little  by  little,  the  mucous  membrane  subsided,  there  were  several  normal 
passages,  the  colic  became  less  frequent  and  less  severe,  and  disappeared 
finally  after  some  violent  pain  which  the  evacuation  of  a  considerable 
quantity  of  hard  faecal  matter  provoked.  "  From  that  time  the  passages 
were  daily  and  easy,  the  local  symptoms  became  definitely  better.  The 
flesh  returned,  the  fever  disappeared,  with  it  disappeared  the  yellowish 
tint  of  the  integument,  and  at  the  end  of  three  months  the  patient  was 
completely  cured." 

This  case  is  also  quoted  by  Molliere'  in  full,  as  proof  of  what  may  be 
accomplished  by  anti-syphilitic  treatment  in  syphilitic  stricture.  He  re- 
marks that  one  such  case  seems  to  him  to  pass  all  comment;  and  to  prove 
"what  caution  should  be  used  in  the  diagnosis  of  organic  disease.  That 
nothing  in  fact  was  more  improbable  a  priori  than  the  syphilitic  charac- 
ter of  the  lesions  of  this  patient,  and  that  specifics  saved  him  from 
certain  death.  He  asks:  **  Is  not  one  authorized,  in  the  presence  of  one 
such  extraordinary  fact,  to  lay  down  the  absolute  rule  that  iodide  of 
potash  should  be  employed  in  all  neoplastic  lesions  of  the  rectum?" 

To  my  own  mind  the  case  conveys  a  very  different  lesson  from  the  one 
intended.  It  seems  to  me  to  prove  nothing  with  regard  to  the  effect  of 
internal  medication  in  syphilitic  stricture,  and  to  be  one  more  example  of 
a  diagnosis  of  stricture  based  upon  the  fact  that  a  bougie  met  with  an 
obstruction  at  a  point  beyond  the  limit  of  touch  and  vision.  It  may  be 
a  case  of  syphilitic  stricture  cured  by  treatment,  but  the  history  does  not 
prove  it. 

There  are  various  means  by  which  the  comfort  of  these  sufferers  may 
be  greatly  increased  without  recourse  to  operative  treatment — and  since 
in  many  cases  the  surgeon  is  limited  to  these  means  in  his  efforts  to  afford 
relief  it  is  well  that  they  should  receive  careful  attention.  The  most 
effectual  of  them  will  be  found  to  be  a  careful  regulation  of  the  diet,  the 
administration  of  laxatives  on  occasion,  and  rest.  The  diet  should  con- 
jast  mostly  of  fluids,  preferably  milk.  If  milk  is  complained  of,  soups 
may  be  substituted.  A  certain  amount  of  farinaceous  food  may  also  be 
allowed,  such  as  toast,  crackers,  and  mush  ;  but  milk  is  the  basis  of  the  diet, 
and  the  other  things  are  only  intended  to  make  that  diet  endurable. 

'  Op  cit ,  p.  306. 


198  DISEASES    OF   THE   KECTDM    AND    ANUS. 

Many  patients  will  assert  from  the  outset  that  they  cannot  take  milk,  but 
nearly  all  can  take  it,  and  considerable  quanities  of  it,  daily  for  an  indefi- 
nite period  if  a  little  care  is  exercised  in  its  administration. 

The  bowels  should  move  daily  without  straining.  Should  any  medi- 
cation be  necessary  to  secure  this  daily  evacuation  a  mild  laxative  will  be 
found  all  sufficient.  The  mineral  waters  or  Rochelle  or  Glauber's  salts 
answer  every  purpose.  Purgatives  are  always  contra-indicated  in  stricture 
of  any  variety,  because  they  cause  straining  and  tenesmus,  increase  the 
tendency  to  congestion  and  its  consequences,  and  because  where  obstruc- 
tion actually  exists  or  is  threatened,  they  may  do  great  harm  by  exciting 
violent  peristaltic  action  in  an  already  weakened  and  ulcerated  bowel. 
The  opposite  condition  of  diarrhoea  is  more  difficult  to  meet  and  often, 
cannot  be  controlled  by  direct  medical  treatment,  depending  as  it  does  on 
the  ulceration  associated  with  the  stricture.  It  is  best  met  by  diet,  rest 
in  the  recumbent  posture,  and  bismuth  with  morphine. 

The  general  strength  of  these  patients  is  to  be  supported  in  every  pos- 
sible way,  and  in  all  of  them  where  it  can  be  borne  cod-liver  oil  will  be 
found  to  answer  a  good  purpose. 

When  obstruction  actually  exists,  much  may  be  done  in  the  way  of 
general  treatment  before  resorting  to  operation.  Food  should  be  almost 
absolutely  suspended;  opium  should  be  given  in  large  doses,  to  allay  the 
peristaltic  action  of  the  intestine,  and  large  poultices  covering  the 
abdomen  will  be  found  to  give  great  relief  to  the  suffering.  Dr.  Norman 
Kerr  has  derived  great  benefit  from  the  administration  of  the  extract  of 
belladonna  in  doses  of  one  or  two  grains  at  short  intervals,  in  this  condi- 
tion, but  the  rationale  of  its  operation  is  not  understood.  No  purgatives 
should  be  administered,  and  the  bowel  should  not  be  tapped  Avith  the 
aspirator.  The  dangers  of  this  measure  have  already  been  pointed 
out. 

By  these  means  combined,  possibly  with  gentle  dilatation,  the  life  of 
a  patient  may  be  prolonged  in  comfort.  I  have  often  been  agreeably 
surprised  at  the  happy  results  of  such  measures,  where  operative  inter- 
ference was  either  declined  or  contra-indicated,  and  they  can  never  be 
dispensed  with,  though  an  operation  be  performed. 

The  various  surgical  procedures  at  our  command  for  overcoming 
stricture  of  the  rectum  may  be  considered  in  the  following  order:  1. 
Dilatation.     2.  Division.     3.  Colotomy. 

1.  Dilatation. — This  may  be  either  gradual  or  sudden,  partial  or 
complete.  The  use  of  bougies  for  gradual  dilatation  is  an  example  of  a 
good  i^ractice  originating  in  false  ideas.  It  was  first  adopted  with  the 
idea  of  destroying  the  stricture  by  the  effect  of  medicinal  substances 
applied  in  this  way;  experience,  however,  soon  proved  that  simple 
bougies  were  not  less  efficacious  than  medicated  ones,  and  the  improve- 
ment was  then  supposed  to  be  due  merely  to  the  mechanical  stretching  of 
the  part,  and  the  instruments  were  introduced  as  often,  and  allowed  to 


NON-MALIGNANT    STRICTURE    OF   THE    RECTUM.  199 

remain  in,  as  long  as  possible,  an  idea  still  very  popular.  But  as  Syme' 
pointed  out,  "  it  is  the  eflEusion  of  organizable  matter  in  the  cellular 
texture  of  the  part  which  causes  the  stricture,  and  it  is  the  absorption  of 
this  deposit  which  removes  the  disease.  The  bougie,  by  its  pressure, 
excites  the  action  of  absorption;  and  if  the  pressure  be  too  great,  too 
long  continued,  or  too  frequently  repeated,  there  will  be  a  great  risk  of 
causing  more  than  sufficient  irritation  for  the  purpose,  and  of  inducing 
again  the  very  condition  it  is  desired  to  counteract,  the  consequences  of 
which  must  be  a  confirmation  and  increase  of  the  disease." 

The  rules  which  should  guide  the  surgeon  in  this  method  of  treatment 
:ire  now  well  understood  and  generally  admitted.  The  dilatation  should  be 
intermittent,  and  not  constant.  Attempts  at  constant  dilatation  by  means 
of  bougies  of  any  sort  which  shall  remain  permanently  in  place  generally 
result  either  in  failure  or  actual  disaster.  They  are  not  well  borne  by  the 
patient,  and  when  their  use  is  persisted  in,  in  spite  of  the  protest  which 
nature  is  pretty  sure  to  make,  the  rectum  becomes  irritable,  the  suffer- 
ing is  greatly  increased,  and  the  patient  is  exposed  to  the  risk  of  peri- 
tonitis and  cellulitis. 

The  dilatation  should  never  be  forced.  A  bougie  should  be  chosen 
which  will  readily  pass  the  obstruction  without  stretching,  and  if  there 
be  any  doubt  in  the  operator's  mind  as  to  the  proper  size  of  the  instru- 
ment to  be  used,  let  one  be  selected  which  is  too  small  rather  than  too 
large.  The  instrument  should  seldom  be  passed  more  than  every  alter- 
nate day,  and  once  a  week  may  be  often  enough.  Little  is  gained  by 
allowing  it  to  rest  for  any  length  of  time  within  the  constriction. 

Practised  in  this  way,  much  good  may  be  done  by  this  treatment. 
The  patient  may  be  greatly  relieved,  and  made  very  comfortable;  but  it 
must  be  continued  indefinitely.  For  this  reason,  I  suppose  it  is  not 
infrequently  used  under  false  pretences  in  cases  of  hypothetical  stricture 
in  hypochondriacal  patients;  and  most  of  the  reported  cases  of  cure  will 
be  found  reported  by  the  laity.  It  has  happened  to  me  more  than  once 
not  to  be  able  to  find  any  stricture  after  a  patient  had  submitted  to  a 
long  course  of  supposed  dilatation,  and  there  is  but  one  way  of  con- 
vincing the  patient  under  such  circumstances.  It  consists  simply  in 
passing  a  full-sized  instrument  its  whole  length  into  the  bowel. 

In  cases  where  the  stricture  is  associated  with  much  ulceration,  dila- 
tation by  bougies  is  very  apt  to  make  matters  worse  instead  of  better, 
and  in  such  cases  I  seldom  employ  it  in  my  own  practice  and  have  seen 
much  suffering  caused  by  it  in  the  practice  of  others. 

This  treatment  by  gradual  dilatation,  perhaps  on  account  of  the 
recent  great  a<.lvance3  which  have  been  mjule  in  the  treatment  of 
stricture,  has,  to  a  certain  extent,  been  superseded  by  more  radical 
measures.     It  is  not  long  since  a  well-written  article  on  rectotomy  in  one 

'  Op.  cit.,  p.  120. 


200  DISEASES    OF    THK    RECTUM    AND    ANUS. 

of  our  periodicals  was  begun  by  the  statement  that  the  treatment  of 
stricture  by  dilatation  was  acknowledged  to  be  a  failure.  This  is  by  no 
means  the  case.  The  measure  may  not  be  curative,  but  it  is,  perhaps, 
as  valuable  a  palliative  as  is  at  the  command  of  the  surgeon.  It  need 
not  always  be  done  with  a  bougie;  for  tlie  patient's  own  finger  or  that  of 
a  careful  nurse  is  often  better  than  any  instrument.  It  is  applicable  to 
all  strictures,  malignant  or  benign,  which  are  within  reach  of  the  anus. 
When  the  disease  is  high  up,  it  is  not  free  from  danger,  and  can  scarcely 
be  recommended,  on  account  of  the  uncertainty  and  diflQculty  of  its 
application. 

I  have  said  that  this  treatment  by  gradual  dilatation  was  not  curative, 
and  must  be  continued  indefinitely.  I  have  seen  no  exceptions  to  this 
rule,  though  many  of  them  are  reported.  In  years  gone  by,  this  treat- 
ment and  that  of  forcible  dilatation  or  divulsion  were  about  the  only 
means  of  dealing  with  this  affection.  Now  we  have  better  ones  which 
will  shortly  be  described. 

Divulsion.  The  dilatation,  instead  of  being  gradual,  may  be  sudden 
and  complete.     For  this  purpose,  yarious  instruments  have  been  in- 


FiG.  49. 

vented,  all  of  them  with  the  idea  of  tearing  open  the  constriction  by  the 
use  of  a  considerable  amount  of  force.  One  of  these  is  shown  in  Figure 
49.  More  recently,  advantage  has  been  taken  of  fluid  pressure,  and  an 
instrument  has  been  invented  by  Wales,  which  is  shown  in  Figure  50. 

Of  all  the  instruments  for  forcible  dilatation,  this  is  perhaps  the  best. 
There  are  now  several  cases  on  record  where  forcible  stretching  with  the 
fingers,  either  with  or  without  previous  nicking  with  a  knife,  has  been 
followed  by  immediate  relief  to  obstruction  and  faecal  accumulation.' 

What  may  be  accomplished  by  this  method  is  well  shown  in  the  fol- 
lowing successful  case  from  Smith.*  "I  was  called  by  Dr.  Vine  to  see 
a  military  officer,  aged  40,  who  had  returned  from  India  in  the  most  mis- 
erable plight.  He  had  suffered  for  several  years  from  chronic  diar- 
rhoea, and  had  not  got  relief  from  any  measures,  and  six  months  pre- 
viously he  had  been  recommended  by  a  medical  board  to  go  by  sea  to 
England.  On  his  arrival  at  Southampton,  on  his  way  to  Edinburgh, 
his  native  town,  he  Avas  so  ill  that  he  determined  to  stop  in  London,  and 

'Smith,  op.  cit.     Dr.  J.  M.  Matthews,  of  Louisville,  Ky.,  has  recorded  one 
remarkably  successful  case  of  this  kind. 
^  Sur^erv  of  the  Rectum. 


MON-MALIONANT  BTBIOTURB   OF  THE   BEOTUM. 


201 


when  he  arrived  there  he  sent  for  Dr.  Vine,  who,  on  hearing  his  his- 
tory, at  once  suspected  something  wrong  with  his  rectum,  and  making  an 


Fio.  50. 


examination,  found  an  obstruction.     I  was  requested  to  see  him,  and  I 
found  the  patient  exactly  in  the  condition  of  one  suffering  from  strangu- 


202  DISEASES    OF   THE    RECTUM    AND    ANUS. 

lated  hernia;  he  was  constantly  vomiting,  complaining  of  pain,  and  the 
countenance  was  anxious,  and  he  was  much  emaciated;  the  abdomen  was 
immensely  distended,  and  it  was  clear  that,  if  some  relief  were  not  soon; 
given,  this  gentleman  would  die. 

**In  conjunction  with  Dr.  Vine,  I  made  a  most  careful  examination,^ 
and  I  found,  on  introducing  the  finger  into  the  bowel  as  far  as  possible, 
that  it  met  with  an  obstruction,  but  after  some  time  I  discovered  what 
appeared  to  be  the  opening  of  the  stricture,  more  like  a  dimple  than 
aught  else.  I  was  enabled  to  introduce  through  this  a  No.  10  gum-elas. 
tic  catheter,  and  through  this  instrument  some  faecal  matter  and  air 
came.     I  was  thus  made  to  see  that  I  had  got  beyond  the  stricture. 

*'  On  the  following  day,  the  patient  was  placed  under  chloroform,  and 
I  guided  a  long,  straight,  probe-pointed  knife  very  carefully  along  the 
side  of  my  left  index  finger,  and  fortunately  got  its  point  into  the  orifice 
of  the  stricture.  I  nicked  this  on  either  side,  and  then  got  the  point  of 
my  finger  into  the  obstruction,  and  dilated  the  orifice  as  much  as  I  could, 
whereupon  an  enormous  quantity  of  faecal  matter  was  emitted,  deluging 
the  bed,  and  placing  myself  and  my  assistants  in  a  most  unenviable  posi- 
tion. The  abdomen  became  quite  flat,  and  the  patient  became  at  once 
immediately  relieved.  No  bad  results  followed  this  operation;  in  three 
days  we  commenced  dilatation  by  bougies,  and  I  was  soon  enabled  to  pass 
a  full-sized  rectum-bougie  through  the  stricture.  In  a  fortnight  I  took 
my  leave  of  the  patient,  recommending  Dr.  Vine  to  pass  the  bougie 
daily.  I  heard  a  few  weeks  afterwards  that  the  patient  had  gone  to 
Edinburgh  convalescent,  and  able  to  introduce  the  bougie  for  him- 
self." 

In  spite  of  a  few  such  successful  cases  as  the  one  above,  this  method 
of  treatment  has  but  few  upholders,  because  it  has  been  found  to  pos- 
sess no  advantages  over  more  gradual  dilatation,  and  to  be  in  itself  by 
no  means  devoid  of  danger.  The  dangers  are  haemorrhage,  laceration 
and  rupture  of  the  bowel,  peritonitis,  and  abscess.  The  relief  ob- 
tained is  not  permanent,  and  the  operation  involves  the  subsequent 
use  of  gradual  dilatation  to  preserve  the  calibre  gained.  Even  when 
applied  to  the  lower  three  inches  of  the  bowel,  the  operation  is  rough, 
uncertain,  and  unsurgical,  and  above  this  point  it  is  scarcely  admissible. 
Nevertheless,  it  has  occasionally  served  a  good  purpose,  and  a  few  happy 
results  are  recorded  m  cases  of  linear  contraction. 

Division  of  the  Stricture. — The  practice  of  nicking  a  linear  stricture 
in  two  or  three  places  as  a  first  step  in  the  treatment  by  dilatation  is  a 
good  one,  and  generally  devoid  of  danger.  It  can  usually  be  done  en- 
tirely by  the  sense  of  touch  with  a  straight,  blunt-pointed  bistoury 
passed  along  the  left  index  finger  as  a  guide. 

The  operation  of  internal  proctotomy  consists  in  dividing  the  whole 
of  the  stricture  tissue  in  the  median  line,  either  anteriorly  or  posteriorly. 
It  is  called  internal  because  the  incision  is  confined  within  the  rectum. 


NON-MALIGNANT   8TRICTUKE   OF   THE    KECTDM.  203 

and  does  not  involve  the  sphincter;  and  it  is  generally  performed  with 
the  knife  in  preference  to  the  cautery  or  ecraseur. 

Regarding  this  operation,  there  is  not  very  much  to  be  said.  It  in- 
volves no  new  principle  of  treatment,  and  would  seem  to  rank  rather 
with  the  older  procedures,  such  as  nicking  and  dilatation,  than  as  a  sub- 
stitute for  colotomy.  There  have  been  many  unpublished  cases,  espe- 
cially in  Xew  York,  and  I  should  probably  express  the  general  feeling  of 
the  profession,  were  I  to  say  that  it  is  not  looked  upon  with  very  great 
favor.  Though  at  first  sight  it  might  appear  less  serious  than  the  ex- 
ternal operation,  it  is  probably  the  more  dangerous  of  the  two — the 
sphincter  preventing  the  free  discharge  from  the  wound  and  increasing 
in  this  way  the  liability  to  pelvic  inflammation.  This  muscle  should  at 
least  be  stretched  as  a  primary  step  in  the  operation,  and,  when  possible, 
a  large  drainage-tube  should  be  left  in.  The  danger  of  haemorrhage  is. 
not  very  great  when  the  incision  is  confined  to  the  median  line,  but, 
should  there  be  trouble  from  this  cause,  the  advantage  of  a  free  external 
wound  in  controlling  it  will  at  once  be  manifest.  When  the  cut  is  ante- 
rior  as  well  as  posterior,  the  anatomical  relations  must  be  borne  in  mind, 
lest  the  peritonaeum  in  the  female,  or  the  bladder  in  the  male,  be 
wounded.  The  following  case  represents  my  entire  experience  with  the 
operation,  which  I  abandoned  after  once  trying,  being  convinced  of  the 
advantages  of  the  external  incision,  next  to  be  described. 

Case  XIX. — Mrs. ,  age  twenty-six.     This  patient  was  a  woman 

with  a  syphilitic  history.  The  stricture  was  of  eight  years'  growth,  and 
had  previously  been  treated  both  by  nicking  and  by  gradual  dilatation. 
As  a  result  of  this  treatment,  she  describes  an  attack  of  "inflammation 
of  the  bowels,"  which  made  her  very  dangerously  sick.  The  stricture 
was  two  and  one-half  inches  from  the  anus,  was  of  just  sufficient  calibre 
to  engage  the  end  of  the  index  finger,  and  did  not  involve  more  than  one 
inch  of  the  bowel,  though  there  was  the  usual  amount  of  ulceration 
above  it. 

I  divided  the  stricture  by  a  single,  deep,  posterior  incision,  which 
did  not  implicate  the  sphincter,  and  the  operation  was  followed  by  an 
attack  of  pelvic  peritonitis,  which  very  nearly  cost  the  patient  her  life. 
This  may  have  been  due  to  the  operation,  or  it  may  have  been  due  to 
attempts  at  subsequent  dilatation  which  was  begun  early  and  followed 
with  perhaps  too  great  vigor;  but  it  was  certainly  excited  by  the  patient 
leaving  her  bed,  going  down-stairs,  indulging  freely  in  wine,  and  submit- 
ting to  the  embraces  of  her  lover.  ' 

Three  months  after  the  operation,  I  completely  lost  track  of  the  case. 
At  that  time  the  calibre  of  the  stricture  was  so  much  increased  as  to  per- 
mit of  easy  digital  examination  of  the  parts  above.  The  increased  size 
seemed  due  entirely  to  a  deficiency  in  the  old  cicatricial  tissue  at  the 
point  of  incision;  the  rest  of  the  circumference  of  the  part  having  much 


204  DISEASES    OF    THE    RECTUM    AXD    ANUS. 

the  same  feel  as  before  the  operation.  The  act  of  defecation  was  much 
less  painful,  and  her  condition  was  altogether  much  better. 

I  never  counted  the  case  as  proving  anything  concerning  the  value  of 
.the  operation  until  a  few  months  ago,  and  more  than  four  years  after  its 
performance.  In  fact,  I  had  little  doubt  that  the  contraction  had  re- 
turned, and  supposed  the  patient  had  either  succumbed  to  the  disease  or 
submitted  to  colotomy.  At  that  time,  however,  the  woman  was  in  per- 
fect health  and  spirits,  and  since  then  I  have  thought  better  of  the  ope- 
ration. I  would  have  given  much  for  a  rectal  examination  after  so  long 
an  interval,  but  it  could  not  be  obtained. 

Other  cases  of  similar  operations  have  been  reported  in  this  country 
with  equally  good  results.' 

External  proctotomy  involves  not  only  the  division  of  the  stricture, 
but  of  all  the  parts  below,  including  the  anus.  This  is  the  operation 
usually  accredited  to  Nelaton,  and  more  recently  advocated  by  Verneuil, 
Panas,  and  others.  It  may  be  performed  in  several  ways,  and  with  the 
knife,  galvano-cautery,  or  ecraseur.  ^The  operations  with  the  galvano- 
cautery  and  ecraseur  were  invented  by  Verneuil,"  and  have  been  practised 
by  him  more  than  by  any  other  surgeon. 

The  operation  as  performed  by  him  consists  in  passing  the  left  index- 
finger  through  the  stricture  as  a  guide,  and  then  plunging  a  trocar  from 
a  point  in  the  median  line,  just  in  front  of  the  tip  of  the  coccyx, 
into  the  rectum,  on  to  the  tip  of  the  finger  above  the  stricture.  After 
drawing  out  the  trocar,  a  fine  bougie  is  passed  through  the  canula  into 
the  rectum,  and  brought  out  at  the  anus.  Removing  the  canula,  the 
bougie  is  replaced  by  the  chain  of  the  ecraseur,  and  the  operation  is  com- 
pleted. 

The  same  section  may  be  accomplished  by  repeated  strokes  of  the  gal- 
vano-cautery or  thermo-cautery  knife.  Both  these  measures  are  intended 
simply  to  prevent  haemorrhage,  and  have  no  other  advantage  over  the 
knife,  and  by  any  of  the  methods  all  of  the  stricture  tissue  and  the  parts 
below  may  be  divided. 

'  Whitehead — Old  fibrous  stricture:  anterior  and  posterior  incision  with  bis- 
toury, followed  by  dilatation.  Two  months  later,  much  improved;  passages  large 
and  natural;  dilatation  continued.  Amer.  Jour.  Med.  Sc,  Jan.,  1871.  Lente 
— Fibrous  stricture  and  fistula;  incision  followed  by  dilatation.  Three  months 
later,  much  relieved,  with  prospect  of  entire  cure  by  continuing  the  use  of  bou- 
gies. Amer.  Jour.  Med.  Sc,  July,  1873.  Beane— Probably  syphilitic;  incision 
both  anterior  and  posterior,  followed  by  use  of  dilators.  Seven  months  after, 
cure  of  ulceration  and  of  many  bad  symptoms,  but  tendency  to  recontraction. 
Amer.  Jour.  Med.  Sc,  April,  1878. 

'  Verneuil  :  Des  retrecissements  de  la  partie  inferieure  du  rectum,  et  de  leur 
traitement  curatif  ou  palliatif  par  la  rectotomie  lineaire,  ou  section  longitudinale 
de  I'intestin  a  Taide  de  I'ecraseur.  Gaz.  des  Hop..  October  26th,  29th;  November 
7th,  9th,  12th.  16th,  19th,  1872.  Traitement  palliatif  du  cancer  du  rectum  au 
moyen  de  la  rectotomie  lineaire.     Gaz.  Hebdom,  March  27th,  1874. 


NON-MALIGNAMT   6TBICTURB   OF   THE    BECTUM.  205 

Nelaton's  method  was  the  simplest  of  all,  and  was  to  introduce  the 
left  index  finger  as  far  as  the  stricture,  and  with  this  as  a  guide,  to  pass 
in  a  blunt  bistoury,  and  divide  all  the  soft  parts  below  the  stricture  as 
nearly  as  possible  in  the  median  line.  By  pulling  open  the  lips  of  this 
incision,  the  stricture  comes  plainly  into  view,  and  may  be  divided  by  a 
second  incision. 

In  performing  the  operation,  I  prefer  the  knife  to  all  other  methods 
of  cutting,  and  have  had  one  specially  adapted  for  the  purpose,  which  is 
shown  in  Fig.  61. 

It  is  simply  the  lithotomy  knife  of  Blizard,  made  heavier  in  the  back 
and  at  the  handle,  for  with  an  ordinary  bistoury  there  is  great  risk  of 
breaking  the  blade  in  the  midst  of  the  stricture  tissue,  which  is  often  as 
hard  as  cartilage,  and  thus  having  an  awkward  accident.  The  blunt 
point  on  the  end  of  the  blade  is  a  great  convenience  in  passing  the  knife 
along  the  index  finger,  avoiding  as  it  does,  all  risk  of  wounding  the 
operator. 

The  best  position  for  the  patient  is  the  lithotomy  position,  and  the 
whole  incision  may  be  made  at  one  stroke.  The  blade  should  be  passed 
fairly  through  the  stricture  before  the  cutting  is  begun,  then  the  stric- 
ture  is   divided   completely,  as  near  as  possible  in   the   median   line 


Fig.  51. 


posteriorly,  and  finally  the  incision  is  continued  downwards  and  out- 
wards, growing  deeper  as  it  approaches  the  perineum,  till  finally  all 
the  soft  parts  are  severed  between  the  anus  and  the  tip  of  the  coccyx. 
In  this  way,  a  large  triangular  wound  is  made,  the  apex  being  within 
the  rectum,  above  the  stricture,  and  the  base  at  the  skin,  and  all  the 
stricture  tissue  is  com])letely  cut  through. 

There  will  generally  be  a  free  gush  of  blood  when  the  cut  is  made, 
but  I  have  never  seen  so  much  as  to  make  me  prefer  the  ecraseur  or 
cautery  operation  in  preference  to  the  knife.  Tiie  rectum  should  at 
once  be  packed  in  the  manner  already  described,  without  waiting  to  try 
any  other  method  of  stopping  the  bleeding.  This  is  a  precaution  which 
should  never  be  omitted. 

This  operation  may  be  modified  in  various  ways  to  fulfil  any  special 
indication.  In  extensive  cancerous  disease,  I  have  sometimes  made  two 
such  cuts,  and  taken  out  a  considerable  mass  of  the  gi'owth  between 
them,  merely  for  the  purpose  of  opening  the  canul. 

It  may  be  asked.  Why  should  so  large  an  incision  be  made,  and  so 
much  tissue  be  divided  below  the  actual  disease?  The  answer  is  simple. 
In  the  first  place,  this  incision  provides  for  free  drainage  and  discharge 
in  the  most  effectual  of  all  ways,  by  furnishing  a  dependent  gutter- 


206  DISEASES    OF    THE    RECTUM    AND    ANUS. 

shaped  opening  which  cannot  become  closed.  This  is  better  than  any 
number  of  drainage  tubes,  and  it  is  this  alone  which  makes  the  external 
operation  a  safer  one  than  the  apparently  slighter  internal  incision. 

In  the  second  place,  by  this  incision,  the  sphincter  is  completely  di- 
vided, and  another  great  point  is  gained.  The  operation  we  are  now 
considering,  it  should  be  remembered,  is  nothing  less  than  a  substitute 
for  colotomy  in  the  same  class  of  severe  cases  for  which  that  operation  is 
generally  considered  the  only  relief.  One  point  which  is  exceedingly 
well  brought  out  by  a  study  of  these  cases  is  the  important  part  played 
by  the  sphincter  muscle  in  the  sufferings  accompanying  severe  cases  of 
stricture  and  ulceration,  and  the  relief  which  may  be  obtained  by  its 
simple  division  without  interference  with  the  stricture  itself. 

In  one  case  of  Verneuil's,  for  example,  there  was  a  stricture  high  up, 
and  yet,  under  a  mistaken  diagnosis  of  spasmodic  stricture  at  the  anus, 
the  sphincter  was  cut  through  with  the  galvano-cautery,  while  the  real 
cause  of  the  trouble  was  untouched,  and  yet  there  was  entire  relief  from 
suffering.  The  same  experience  has  been  repeated  often  enough  to  es- 
tablish the  general  principle,  that  free  division  of  the  sphincter  is  not 
only  a  justifiable  therapeutic  measure  for  the  relief  of  the  pain  attendant 
upon  either  benign  or  malignant  stricture  or  ulceration,  but  is  often  the 
best  means  at  the  surgeon's  command  for  allaying  suffering. 

By  the  external  operation,  then,  the  obstruction  is  divided,  and  one 
great  cause  of  suffering  is  abolished,  and  both  are  effected  by  the  same 
stroke  of  the  knife. 

The  after-treatment  of  the  incision  is  very  simple.  When  the  rectum 
has  been  tightly  packed  with  picked  lint,  it  will  usually  cause  more  or 
less  uneasiness  on  the  following  day,  unless  the  patient  be  under  the  in- 
fluence of  opium.  For  this  reason,  I  generally  remove  enough  of  it  on 
the  following  day  to  give  the  patient  ease,  and  the  remainder  is  allowed 
to  remain  until  suppuration  has  commenced.  It  may  usually  all  be  picked 
out  by  the  third  or  fourth  day  without  causing  any  pain.  The  subse- 
quent treatment  of  the  incision  itself  consists  wholly  in  cleanliness,  which 
may  be  obtained  by  gently  syringing  the  part  with  warm  water  and  a 
little  carbolic  acid.  No  particular  attention  need  be  given  to  regulating 
the  passages.  The  first  one  after  the  operation  will  often  be  the  only 
comfortable  one  the  patient  has  experienced  for  years,  and  unless  there 
is  some  special  reason  for  interference,  they  may  be  left  entirely  to  nature. 

The  case  Avhich  follows  will  give  a  very  fair  idea  of  what  may  be 
hoped  for  from  this  method  of  treatment  : 

Case  No.  XX. — Mrs,  ,  age  35,  mother  of  one  child  twelve 

years  old.  The  patient  has  always  suffered  from  obstinate  constipation, 
and  several  years  ago  was  relieved  artificially  of  impaction  of  faeces.  Her 
husband,,  a  physician,  assures  me  that  there  is  no  venereal  history,  nor  is 
there  any  reason  to  suspect  any  such.  The  symptoms  of  rectal  trouble 
began  six  years  after  marriage,  at  which  time  she  was  operated  upon  for 


NON-MAUONANT   STRICTURE    OF   THE    RECTUM.  207 

large  internal  haemorrhoids.     Soon  after  this  she  began  to  suffer  with 
the  usual  symptoms  of  ulceration  of  the  rectum. 

The  examination  revealed  advanced  ulceration  of  the  whole  circum- 
ference of  the  rectum,  with  a  stricture  about  an  inch  and  a  half  up,  which 
just  admitted  the  end  of  the  index  finger.  In  connection  with  the  stric- 
ture there  were  two  fistulae.  For  this  condition  the  patient  had  submit- 
ted to  the  usual  treatment  by  dilatation,  but  without  relief.  Her  gen- 
eral condition  was  such  as  is  usually  seen  in  advanced  rectal  disease. 
She  had  lost  flesh  and  appetite,  and  the  suffering  was  extreme.  What 
she  most  dreaded  was  an  action  of  the  bowels,  so  great  was  the  pain  at- 
tendant upon  it. 

The  operation  which  I  have  described  was  performed.  One  of  the 
fistulae  was  also  cut,  but  the  other  was  left  to  the  chance  of  sponta- 
neous closure,  since  it  communicated  with  both  rectum  and  vagina,  and 
the  usual  operation  for  recto- vaginal  fistula  would  have  been  necessary 
had  any  interference  been  practised.  The  operation  was  attended  with 
considerable  haemorrhage,  which  was  controlled  by  stuffing  the  rectum . 
with  picked  lint,  after  the  ulcerated  surfaces  both  above  and  below  the 
stricture  had  been  renovated  by  scraping  them  with  the  handle  of  a 
scalpel. 

The  subsequent  treatment  consisted  merely  in  absolute  rest  in  bed 
and  milk  diet,  with  a  dressing  of  the  wound  by  the  introduction  of 
picked  lint.  No  attempt  was  made  at  passing  a  bougie,  and  the  stricture 
was  left  entirely  to  itself.  The  immediate  effect  of  the  operation  was  a 
most  marked  and  satisfactory  relief  of  the  most  painful  symptoms.  The 
passages  were  involuntary,  but  were  jjainless  and  always  preceded  by  a 
warning  sensation,  which  gave  the  patient  ample  time  to  prepare  herself. 
At  the  end  of  six  weeks  she  had  improved  greatly  in  general  condition, 
and  was  more  comfortable  than  at  any  time  since  the  trouble  began. 
The  passages  were  of  normal  shape  and  occurred  painlessly  once  a  day. 
They  were  under  the  control  of  the  will,  but  there  was  incontinence  of 
wind.  In  this  condition  the  patient  returned  to  her  home  in  the  West 
under  the  care  of  her  husband. 

Six  months  later,  she  again  came  to  New  York  for  treatment,  not 
from  any  return  of  the  pain,  but  because  of  the  discharge  from  the  bowel, 
and  the  occasional  annoyance  which  arose  from  the  incontinence  of  wind. 
Her  general  condition  was  excellent,  and,  except  for  the  two  things 
mentioned,  she  would  have  considered  herself  in  perfect  health.  An 
examination  showed  a  very  marked  decrease  and  softening  down  in  the 
stricture  tissue;  the  wound  made  with  the  knife  had  never  entirely 
healed,  the  patient  having  exercised  freely  and  constantly  while  at  home, 
and  there  were  two  distinct  lines  of  ulceration  within  the  anus;  one  on 
the  anterior  surface,  sujierficial,  about  half  an  inch  broad  and,  an  inch 
and  a  half  long;  the  other,  at  the  site  of  the  cut  behind,  deeper,  and 
running  further  up  the  bowel.     Otherwise  the  old  ulceration  was  entirely 


208  DISEASES    OF    THE    EECTDM    AND    ANUS. 

healed,  and  its  site  marked  by  a  thin,  shining  bluish- white  cicatricial 
surface. 

Attention  was  at  once  turned  to  the  treatment  of  this  ulceration.  The 
patient  was  put  upon  almost  absolute  milk-diet,  and  after  awliile  was  also 
confined  absolutely  to  her  bed.  The  remnant  of  the  old  incision  was 
induced  to  heal  by  daily  dressings  of  lint  and  balsam  of  Peru,  and  the 
ulceration  above  was  treated  by  applications  of  bismuth,  opium,  nitrate 
of  silver,  balsam  of  Peru,  iodoform,  and  oxide  of  zinc,  alone  and  in  com- 
bination. At  the  end  of  a  couple  of  months  she  was  so  nearly  well  that 
attention  was  turned  to  the  recto-vesical  fistula.  The  openings  into  the 
rectum  and  vagina  Avere  both  small,  but  there  was  a  considerable  abscess 
cavity  in  the  recto-vaginal  wall  which  discharged  into  each  canal.  This 
cavity  was  freely  laid  open  into  the  rectum.  At  the  end  of  three  months 
the  ulceration  on  the  anterior  wall  of  the  rectum  had  entirely  healed, 
that  on  the  posterior  wall  had  nearly  healed,  the  incision  had  cicatrized, 
and  the  abscess  cavity  had  closed  except  an  exceeedingly  fine  and  tortu- 
ous canal  leading  from  the  rectum  into  the  vagina.  The  discharge  from 
the  rectum  had  practically  ceased,  and  in  this  condition,  which  certainly 
warranted  a  prognosis  of  complete  and  speedy  recovery,  she  returned  to 
her  home  to  continue  the  treatment  for  a  few  weeks  longer  till  she  should 
be  entirely  well.  Two  months  later  I  again  heard  from  her,  and  the 
report  was  most  favorable. 

This  case  is  certainly  worthy  of  a  careful  consideration.  When  the 
lady  applied  to  me,  all  the  supposed  resources  of  rectal  surgery  had  been 
exhausted  except  colotomy.  I  do  not  think  I  exaggerate  when  I  say  that 
most  surgeons  would  have  at  once  decided  in  favor  of  colotomy,  and 
would  have  been  justified,  of  course,  in  so  deciding,  for  colotomy  is  still 
the  recognized  mode  of  treatment  in  these  cases.  In  my  own  mind, 
colotomy  was  always  present  as  the  dernier  ressort,  but  having  tried  proc- 
totomy in  several  instances,  and  been  more  or  less  satisfied  with  its 
results,  I  determined  to  make  this  a  test  case.  The  result  was  most 
happy,  and  yet  there  is  nothing  exceptional  in  that  result,  though  the 
great  tractability  of  the  patient,  and  her  determination  to  do  all  that 
•was  asked  of  her,  alone  rendered  it  possible. 

In  an  analysis  of  cases  made  some  time  since,'  I  found  that  in  eighteen 
cases  of  non-malignant  stricture  treated  in  this  way,  all  the  patients 
were  greatly  relieved  as  to  general  health,  or  local  condition,  or  both. 
In  eight,  kept  under  observation  for  a  period  of  from  three  months  in 
one  case  to  four  years  in  three  cases,  the  cure  was  absolute,  there  being 
no  return  of  the  contraction,  and  in  some  a  disappearance  of  all.  indura- 
tion. A  tendency  to  recontraction  is  mentioned  in  four,  due  in  two 
to  the  fact  that  all  of  the  stricture  Avas  not  divided. 

Brief  notes  of  some  of  these  cases  are  given  below. 

'  External  Rectotomy  as  a  Substitute  for  Lumbar  Colotomy  in  the  Treatment 
of  Stricture  of  the  Rectum.     The  N.  Y.  Med.  Journal,  March,  1880. 


NON-MALIGNANT   STRICTURE    OF   THE    RECTCM.  209 

External  Redotomy  with  the  Knife. 

1.  Panas. — Female,  aged  33.  Syphilitic  stricture,  very  dense  and 
painful;  eight  years'  duration.  Incontinence  for  three  months  after 
operation.  Eighteen  months  later,  described  as  completely  cured. — 
Gaz.  des  Hop.,  Dec,  1872. 

2.  Whittle. — Hard  annular  stricture,  very  close;  one  fistula.  •  Oper- 
ation as  for  ordinary  fistule.  Haemorrhage  troublesome  and  controlled 
by  thermo-cautery.  Three  weeks  later,  "general  health  completely  re- 
stored and  local  condition  greatly  relieved." — Lancet,  June  1st,  1878. 

3.  Panas. — Woman,  aged  40.  Stricture  probably  syphilitic.  Two 
previous  operations  by  slight  internal  incision,  and  two  attempts  at  cure 
by  dilatation.  Patient  very  feeble;  suffering  from  abdominal  distention; 
signs  of  approaching  occlusion;  ovarian  tumor;  diarrha3a  and  vomit- 
ing. Operation  followed  by  relief  of  pain  and  by  great  comfort;  no  ten- 
dency to  return;  vomiting  and  diarrhoea  continued  till  death,  some  time 
after,  from  exhaustion.  Post-mortem  examination  showed  the  complete 
success  of  the  operation,  and  the  division  in  the  fibrous  tissue. — Gaz.  des 
Hop.,  Dec,  1872. 

External  Redotomy  with  the  Ecraseur,    Galvano- Cautery  or  Thermo- 
cautery. 

1.  Trelat. — Ano-rectal  syphiloma,  of  several  years'  duration,  with 
great  thickening,  ulceration,  and  fistulae.  Operation  (kind  not  stated) 
five  years  before,  unsuccessful.  Galvano-cautery.  Nine  days  after  oper- 
ation, pneumonia  and  facial  erysipelas.  Death  in  three  weeks  without 
local  accident. — Prog.  Med.,  June  22d,  1878. 

2.  Verneuil. — Stricture  of  several  years'  duration;  great  induration 
and  tumefaction,  and  twenty  fistulous  tracts.  Three  operations;  first, 
on  one-half  the  fistulae;  second,  on  remainder;  and  third,  on  tlie  stric- 
ture with  6craseur.  Four  months  later,  **  wound  healed  and  functions 
of  the  rectum  entirely  re-estailished." — Gaz.  des  Hop.,  1872,  p.  1,028. 

3.  Verneuil. — Previous  syphilis;  great  constitutional  disturbance; 
scrotum  enlarged  to  three  times  its  natural  size  by  fistulous  tracts,  of 
which  there  were  twelve.  Ecraseur  through  one  of  the  fistulae — others 
operated  on  a  month  later.  Two  years  later,  parts  had  regjiined  their 
suppleness,  and  all  traces  of  disease  had  disappeared. — Loc.  cit. 

4.  Verneuil. — Patient  in  bad  general  condition.  Two  operations 
with  Ecraseur  at  six  weeks  interval.  First,  posterior  rectotomy  with  divi- 
sion of  posterior  fistulae;  second,  anterior  rectotomy  with  division  of  ante- 
rior fistula?.  Incontinence  lasted  only  a  few  days.  There  wjis  marked 
tendency  to  recontraction,  due  to  the  fact  that  the  stricture  was  so  exten- 
sive that  the  chain  was  not  carried  to  its  upper  limit,  and  a  distinct  zone 
of  cicatricial  tissue  was  left. — Loc.  cit. 

5.  Verneuil. — Woman,  reduced  to  last  degree  of  marasmus,  with 

14 


210  DISEASES   OF   THE    RECTUM    AND    ANUS. 

hectic.  Stricture  complicated  with  much  ulceration  above  and  below, 
and  three  or  four  fistulae.  Operation  followed  by  great  relief  of  all  symp- 
toms. After  several  years,  again  examined:  general  condition  still  good, 
but  a  very  appreciable  recontraction  of  a  year's  duration. — Loc.  cit. 

6.  Verneuil. — Stricture  very  close  and  hard;  previous  dilatation  with- 
out effect.  Phlegmon  existing  on  one  side,  and  old  fistula  on  the  other. 
Abscess  laid  open  and  chain  passed  through  it  into  gut  above  stricture. 
Four  years  later,  died  of  phthisis,  having  been  entirely  free  from  symp- 
toms in  mean  time.  Before  death,  stricture  admitted  two  fingers  easily. — 
Loc.  cit. 

7.  Verne uiL. — Constriction  very  hard  and  close;  also  fistula.  It  was 
found  almost  impossible  to  pass  trocar  beyond  the  contraction,  on 
account  of  its  great  hardness,  and  this  was  finally  accomplished  only  by 
boring  a  tract  with  a  pair  of  curved  scissors.  The  ecraseur  required 
three-quarters  of  an  hour  to  cut  through.  Several  months  later,  general 
state  very  satisfactory;  rectal  wall  had  partly  regained  its  suppleness; 
no  difficulty  in  defecation,  but  a  still  appreciable  contraction,  due  to 
the  fibres  which  were  too  high  up  for  the  chain. — Loc.  cit. 

8.  Verneuil. — Previous  syphilis.  General  condition  bad.  Stricture 
consisted  of  a  limited  contraction  of  the  posterior  and  upper  fibres  of 
the  sphincter,  and  disappeared  on  prolonged  pressure  with  the  finger. 
Two  previous  operations,  one  by  internal  incision,  the  other  by  nicking 
and  dilatation.  Division  by  trocar  and  ecraseur;  incontinence  for  a  few 
days;  after  three  weeks,  passages  natural  and  all  symptoms  relieved. 
Three  years  after,  again  examined,  and  found  suffering  from  rectal  syph- 
iloma developed  since  operation,  together  with  tertiary  eruptions. — Loc. 
cit.     [History  completed  by  Tison  in  These  de  Paris.  ] 

9.  Verj^euil. — Previous  syphilis;  stricture  annular;  much  constitu- 
tional disturbance,  great  pain,  diarrhcBa,  colic,  and  discharge  of  pus.  Op- 
eration of  internal  rectotomy  with  thermo-cautery,  followed  by  phleg- 
mon. Abscess  opened  and  external  operation  done  with  thermo-cautery 
through  abscess  cavity.  One  month  later,  telief  of  all  symptoms;  return 
of  suppleness  in  parts;  stricture  admitted  two  fingers  easily;  tendency  to 
recontraction  in  posterior  part  of  rectum;  anterior  part  healthy. — Tison, 
These  de  Paris. 

10.  Verneuil. — Rectal  syphiloma;  anaemia  and  loss  of  flesh;  great 
tenesmus.  Thermo-cautery.  Incontinence  for  three  weeks.  Reported 
completely  cured  after  three  months. — Tison. 

11.  Verneuil. — Stricture,  probably  inflammatory,  with  several 
fistulse.  Thermo-cautery.  Incontinence  for  three  weeks.  After  five 
weeks,  appetite  and  strength  returned;  passages  easy  and  painless. — 
Tison. 

12.  GossELiiq-. — Syphilitic.  Forced  dilatation  three  years  before. 
General  condition  very  bad  from  excesses  of  all  kinds;  passages  very  fre- 
quent and  painful.   Thermo-cautery,  followed  by  temporary  relief.    Four 


NON-MALIGNANT    STRICTURE    OF   THE    RECrtTM.  211 

months  later,   condition  same  as  before,  with   signs  of  commencing 
phthisis. — Tison. 

13.  TiLLAUX. — Valvular  stricture,  posterior,  with  ulceration;  ante- 
rior portion  healthy;  several  fistulae.  Galvano-cautery.  Three  years 
later,  complete  cure,  and  no  return. — Tison. 

14.  TiLLAUX. — Old  stricture,  probably  syphilitic,  with  general 
cachexia — so  great  as  to  resemble  that  of  cancer.  Ecraseur.  Four 
years  later,  remained  completely  cured. — Tison. 

15.  TiLLAUX. — Probably  syphilitic;  previous  rupture  of  perineeum; 
enormous  dilatation  of  anus;  incontinence  of  fluid  faeces;  general  condi- 
tion exceedingly  bad;  signs  of  occlusion;  operation  undertaken  without 
hope  of  cure,  but  to  relieve  worst  symptoms.  Galvano-cautery,  from 
without  inward,  with  cautery  knife.  Life  prolonged  five  months,  with 
freedom  from  suffering. 

16.  Verneuil. — Dysenteric  contraction  high  up,  twelve  centimetres 
from  anus.  Under  mistaken  diagnosis  of  spasmodic  stricture  of  the 
sphincter,  that  muscle  was  divided  with  the  cautery.  Entire  relief  from 
pain,  but  continued  symptoms  of  retention. — Tison. 

17.  Labbe. — Probably  syphilitic;  much  pain;  abscesses;  fistulae. 
Division  with  galvano-cautery,  followed  by  considerable  haemorrhage  and 
tampon.  After  a  time,  slight  return  of  contraction  at  margin  of  anus,  the 
rest  of  gut  remaining  supple.  Second  operation  by  Verneuil  with 
therm o-cautery,  followed  in  the  course  of  six  months  by  prolapse  of  the 
rectum,  which  was  cured  by  cauterization  of  the  posterior  edge  of  the 
an  lis.  Considerable  amelioration  of  suffering. — Tison,  quoted  from 
Cerou,  These  de  Paris. 

18.  Verneuil. — Syphiloma  of  long  standing:  great  anaemia;  intol- 
erable pain;  constant  purulent  discharge;  previous  dilatation  unsuccess- 
ful. Ecraseur,  followed  by  dilatation.  Four  years  later,  absolute  cure. 
No  induration;  sphincter  acting  well. — Tison,  These  de  Paris. 

19.  FocHiER. — Stricture  of  many  years' standing.  Patient  feeble  and 
emaciated;  great  gastro-intestinal  derangement;  two  fistulae.  The  con- 
striction was  first  divided  with  a  bistoury  cache  to  admit  the  finger,  and 
operation  completed  with  ecraseur.  Control  of  sphincter  after  tiie  first 
few  days.  Left  hospital  ten  days  after  the  operation,  with  appetite  and 
digestion  good,  and  general  health  much  improved,  having  soft  passages 
of  the  size  of  the  finger. — Lyon  Med.,  Feb.  20th,  1876. 

Cancers. 

1.  Verneuil. — Cancer.  Ecraseur,  followed  by  immediate  relief; 
decrease  in  induration;  recovery  of  appetite  and  strength.  Death  from 
subsequent  operation  of  excision. — Gaz.  des  Hop.,  1872. 

2.  Verneuil, — Cancer  reaching  beyond  point  of  finger;  sphincter 
continually  in  contraction,  and  violent  pain  caused  by  slightest  touch; 
attempts  at  dilatation  followed  by  phlegmon  and  fistula;   constant  pain 


212  DISEASES    OF    THE    RECTUM    AND    ANUS. 

and  tenesmus,  with  bloody  passages;  insomnia;  rapidly  approaching  fatal 
termination.  The  operation  consisted  merely  in  dividing  the  sphincter 
with  ecraseur  without  touching  the  cancer,  and  the  relief  was  so  great 
that  the  patient  left  hospital  believing  himself  cured.  —  Gaz.  des  Hop., 
Nov.,  1872. 

3.  Verneuil. — Cancer,  with  all  the  usual  symptoms,  and  approach- 
ing occlusion.  Ecraseur;  death  on  ninth  day  from  peritonitis. — Gaz, 
des  Hop.,  Nov.,  1872. 

4.  Verneuil. — Cancerous  stricture  high  up,  and  very  close;  con- 
stant suffering  from  discharges  of  gas  and  pus.  Ecraseur  passed  as  high 
as  possible,  but  not  high  enough  to  divide  upper  portion.  Considerable 
relief;  cessation  of  pain;  passages  easy  for  several  months.  Death 
finally  from  progress  of  disease. — Gaz.  Hehdom.,  Mar.  27th,  1874, 
p.  196. 

5.  Verneuil. — Epithelioma  involving  right  half  of  rectum,  and 
reaching  too  high  for  extirpation;  ulceration;  loss  of  flesh  and  strength; 
great  pain  on  defecation;  retention.  Sphincter  divided  with  chain  on 
left  side  in  such  a  way  as  not  to  involve  the  cancer.  One  year  later, 
freedom  from  pain;  general  state  good;  incontinence  following  opera- 
tion disappeared;  difficulty  in  passage  of  solids  overcome  by  seltzer; 
gradual  advancement  of  cachexia. — Gaz.  Hebdom.,  Mar.  27th,  1874, 
p.  196. 

6.  Verneuil. — Cancer  high  up,  involving  prostate  and  vesiculae 
seminales.  Continued  diarrhoea  and  incontinence,  and  bad  general  con- 
dition. A  double  posterior  external  operation  was  done  with  the  chain, 
and  the  portion  included  between  the  two  incisions  cut  away,  with  tlie 
idea  of  relieving  pain  and  retention  and  opening  a  passage  for  tlie  subse- 
quent application  of  escharotics  to  the  cancer.  Operation  followed  by 
immediate  relief  of  worst  symptoms.  —  Gaz.  Hebdom.,  March  27th, 
1874. 

7.  Nelaton. — Operation  done  with  bistoury.  Relief  continued  till 
death,  eighteen  months  after,  from  extension  of  malignant  disease  to  the 
pelvis. — Panas,  Gaz.  des  Hop.,  1872,  p.  1,149. 

8.  Fochier. — Cancer  of  posterior  part  of  rectum,  reaching  to  height 
of  ten  centimetres.  Great  pain  and  tenesmus;  foetid  and  bloody  dis- 
charge; loss  of  sleep.  Complete  division  with  ecraseur.  Left  liospital 
ten  days  after,  believing  himself  cured.  After  two  months,  had  no  more 
pain  and  no  incontinence,  except  when  suffering  with  diarrhoea.  Had 
two  regular  passages  daily,  and  complained  only  of  not  regaining  his 
strength.  In  this  case,  the  section  extended  to  the  unusual  height  of 
twelve  centimetres  from  the  anus. — Lyon  Med.,  Feb.  20th,  1876. 

I  have  performed  this  operation  in  various  other  cases,  and  have  every 
reason  to  be  satisfied  with  its  results.  In  malignant  or  non-malignant 
stricture  and  ulceration,  I  have  never  seen  it  fail  to  give  immediate  relief 
to  suffering,  and,  as  a  means  of  relieving  the  pain  of  the  disease,  I  believe 


NON-MALIGNANT    STRICTURE   OF   THE   RKCTUM.  213 

it  to  be  fully  equal  to  colotomy.     It  also  fulfils  the  other  great  indication 
for  colotomy,  the  overcoming  and  prevention  of  obstruction. 

Too  much  must  not  be  expected  of  the  operation,  however.  I  have 
seen  several  cases,  one  in  my  own  practice,  and  several  where  I  have  ad- 
vised the  operation  in  consultation  with  others,  which  have  led  to  disap- 
pointment for  this  very  reason.  An  old  stricture  of  the  rectum  with 
extensive  ulceration  is  a  well-nigh  incurable  disease.  Proctotomy  may  be 
relied  upon  with  certainty  to  relieve  the  pain  and  prevent  faecal  obstruc- 
tion even  in  the  worst  cases,  and  in  more  favorable  ones  it  may  effect  a 
practical  cure  by  opening  the  canal,  causing  a  diminution  in  the  indura- 
ion,  and  allowing  the  ulceration  to  heal,  but  it  will  not  cure  them  all- 
Nothing  at  present  known  to  surgery  will.  A  rectum  which  has  once 
been  diseased  to  this  extent  is  never  again  a  healthy  one,  though  it  may 
be  made  a  very  comfortable  one. 

Another  point  which  must  not  be  overlooked  is,  that,  after  proctotomy 
as  after  colotomy,  there  is  still  a  diseased  rectum  which  must  be  treated 
by  every  possible  means;  and  that  the  incision  may  be  only  the  first  step 
in  the  cure.  The  stricture  is  easier  to  overcome  than  the  ulceration 
■which  accompanies  it.  In  the  case  given  above,  I  succeeded  ultimately 
by  long  and  patient  effort  in  curing  that  also,  but  it  cannot  be  done  in 
every  case.  In  many  of  these  cases  the  ulceration  must  be  treated  as 
ulceration  with  the  same  results,  both  good  and  bad,  as  usually  attend 
the  treatment  of  that  most  painful,  obstinate,  and  often  incurable  condi- 
tion. But  the  chances  of  curing  it,  and  at  all  events  of  relieving  it,  are 
infinitely  better  after  the  operation  than  before. 

It  is  understood  that  I  do  not  advocate  the  operation  in  cases  of  dis- 
ease high  up  in  the  bowel,  though  it  may  be  safely  done  at  a  considerable 
distance  from  the  anus,  and  where  an  incision  involving  the  anterior 
wall  would  be  unjustifiable,  for  the  anatomical  reason  that  the  peritoneum 
extends  so  much  lower  in  front  than  behind.  For  other  literature  upon 
this  subject,  the  reader  is  referred  to  the  bibliography  given  below. 

Bibliography. 

Panas:  Du  traitement  des  retrecissements  du  rectum  par  la  rectotomie  exteme, 
Gaz.  des  H6p.,  December,  1872.  p.  1,148. 

Muron,  A. :  Dea  retrecissements  de  I'extr^mite  inferieure  du  rectum,  et  de  leur 
guerison  par  la  rectotomie  lineaire.     Gaz.  Med,  de  Paris,  January  4th.  1873. 

Fochier,  A. :  Sur  {'application  de  la  rectotomie  lineaire  aux  retrecissements 
tres-etendus  du  rectum.     Lyon  Medicale,  February  20th,  1876. 

Pinguet:  Des  retrecissements  du  rectum;  appreciation  des  diverses  m^thodes 
therapeutiques.    Th^de  Paris,  1873,  No.  17. 

Tison:  Nouvelles  considerations  sur  la  rectotomie  lineaire.  These  de  Paris. 
1877. 

Turgis:  Foreign  Body  in  Rectum.  Bull,  de  la  Soc.  de  Chir.,  tome  iv..  No.  10, 
1878,  p.  789. 

Cerou:  Th^  de  Paris,  1875,  No.  390. 


214  DISEASES    OF   THE    KECTUM    AND    ANUS. 

Whitehead,  W.  R. :  Case  of  Fibrous  Stricture  of  the  Rectum  Relieved  by  In- 
cisions and  Elastic  Pressure,  with  Remarks.  Amer.  Jour.  Med.  Sc.,  January, 
1871. 

Whittle,  G. :  Stricture  of  the  Rectum  Divided  by  the  Knife.  Lancet,  June  1st, 
1879,  p.  788. 

Lente,  F.  D. :  Report  of  a  Case  of  Non-Malignant  Stricture  of  the  Rectum,  and 
Remarks  on  the  Surgical  Treatment  of  this  Disease.  Amer.  Jour.  Med.  Sc, 
July,  1873. 

Beane,  F.  D. :  Case  of  Specific  Stricture  of  the  Rectum;  Antero-Posterior 
Linear  Rectotomy;  Recovery;  Remarks  on  the  Operation.  Amer.  Jour.  Med. 
Sc,  April,  1878. 

Discussion  sur  les  retrecissements  du  rectum.  Bull,  de  la  Soc.  de  Chir.,  Paris, 
1873,  p.  83. 

Vemeuil,  etal.:  Rectotomie  et  colotomie  (Soc.  de  Chir.,  Paris).  Prog.  Med., 
January  7th,  1882. 

Eoccision. — The  operation  of  excision,  "which  is  generally  applied  only 
to  cancerous  strictures  and  which  will  be  fully  described  under  that  head, 
has  also  been  applied  to  simple  strictures;  and,  though  I  have  never  done 
it  myself,  I  have  seen  a  few  cases  which  seemed  particularly  adapted  to 
it.  One  such  case  is  reported  by  Dr.  Lowson '  in  which  the  result  was 
comparatively  good,  though  no  better  than  that  obtained  by  proctotomy. 

The  operation  performed  by  him  consisted  in  dividing  the  external 
sphincter  posteriorly,  so  as  to  arrive  at  the  stricture,  pulling  it  down 
through  this  wound  when  possible,  dividing  the  bowel  above  and  below 
it,  dissecting  it  out  from  its  attachments,  and  uniting  the  two  ends  of 
the  bowel  by  sutures.  In  this  case  there  was  considerable  difficulty  in 
the  subsequent  union  of  the  parts,  and  after  healing  had  occurred,  there 
was  considerable  contraction,  but  the  condition  of  the  patient  was  greatly 
improved. 

Oolotomy. — This  is  the  last  resort  of  surgery  in  dealing  with  ulcera- 
tion or  stricture  of  the  rectum.  In  ulceration  it  may  be  a  curative  mea- 
sure; in  stricture  it  is  only  palliative,  and  it  should  therefore  not  be 
undertaken  till  other  measures  have  failed.  It  is  intended  to  fulfil  two 
important  indications,  the  relief  of  pain,  and  preventing  or  overcoming 
obstruction,  and  we  have  already  seen  how  both  of  these  may  be  met  in 
many  cases  by  other  means  which,  even  when  only  partially  successful,  are 
much  preferable. 

When  none  of  the  methods  already  pointed  out  serve  to  assuage 
the  suffering,  and  when  it  is  probable  that  the  suffering  is  not  due  to  an 
irritable  sphincter  muscle,  or  to  pressure  on  neighboring  nerves  from  the 
mass  of  the  deposit,  cancerous  or  otherwise  (in  which  latter  case  colotomy 
cannot  be  expected  to  afford  relief),  and  when  none  of  the  means  already 
described  for  preventing  or  overcoming  obstruction  can  be  applied,  colot- 

'  Case  of  Stricture  of  the  Rectum,  treated  by  Excision  of  the  Stricture.  Lan- 
cet, April  12th,  1879. 


NON-MALIGNANT   8TRICTUKE   OF  THE   EECTUM.  215 

omy  may  be  resorted  to.  There  is,  however,  but  one  class  of  cases  in 
which  obstruction  may  not  be  overcome  by  attacking  the  stricture  itself, 
instead  of  the  bowel  above  it,  and  that  is  where  the  stricture  is  too  high 
to  be  safely  reached  by  the  knife,  and  where,  even  then,  dilatation  is  too 
painful  or  too  dangerous  to  be  admissible. 

Judged  by  these  rules,  colotomy  would  be  limited  to  a  small  propor- 
tion of  cases.  It  would  be  tried  after  division  of  the  sphincter  and  of 
the  stricture  had  each  failed  to  give  relief  in  disease  near  the  anus;  and 
practically  would  be  limited  to  disease  high  up  in  the  bowel.  Such  re- 
strictions as  these  would  greatly  limit  the  number  of  operations  especially 
in  the  United  States,  and  I  am  not  sure  that  this  might  not  be  done  with 
advantage.  We  seldom  see  in  the  reports  of  this  operation  in  current 
literature  any  other  reason  given  for  its  performance  than  the  mere  ex- 
istence of  obstructive  or  painful  disease;  and  yet  I  doubt  if  the  mere 
presence  of  a  stricture  of  the  rectum,  malignant  or  benign,  is  a  justifiable 
reason  for  the  performance  of  this  repulsive  and  serious  operation.  It 
has  yet  to  be  proved  that  colotomy  delays  cancerous  growth,  though  it 
certainly  prolongs  life  by  diminishing  pain  and  overcoming  obstruction. 
But  the  relief  to  the  pain  may  be  and  often  is  only  partial,  for  a  small 
amount  of  faeces  which  has  passed  the  artificial  anus  may  cause  as  much 
suffering  and  tenesmus  as  the  natural  quantity. 

In  almost  direct  proportion  as  the  operations  of  proctotomy  and  of 
partial  or  complete  excision  of  strictures  have  become  popularized  and 
their  advantages  in  suitable  cases  have  become  manifest,  the  operation  of 
colotomy  has  been  limited  and  the  natural  objections  to  it,  both  by  patient 
and  surgeon,  have  been  allowed  more  weight  in  influencing  the  treat- 
ment. Especially  is  this  the  case  in  France,  the  birthplace  of  the  opera- 
tion, and  HI  Germany,  while  England,  as  represented  by  Allingham,  is 
plainly  following  in  the  same  course.  In  this  country  alone  does  coloto- 
my still  hold  its  sway — partly  for  the  reason  that  its  substitutes  have 
never  been  so  thoroughly  tried  here  as  on  the  other  side  of  the  water. 

It  would  be  easy  at  the  present  time  to  collect  a  much  larger  table  of 
cases  of  this  operation  than  was  accessible  to  Mason  when  he  published  his 
paper  on  this  subject,  but  I  do  not  know  that  anything  would  be  added 
to  our  general  knowledge  of  the  subject  by  such  a  labor.  Allingham  had 
operated  at  the  time  of  his  last  edition  twenty-seven  times.  Ilis  best 
result  wjis  obtained  in  a  man  with  a  scirrhous  growth  filling  up  the  pelvis, 
in  whom  life  was  prolonged  four  and  a  half  years  after  the  operation. 
Another  case,  a  woman,  lived  nineteen  months,  twelve  of  them  in  won- 
derful comfort.  Only  three  of  his  patients  died  within  a  fortnight 
of  the  operation,  one  from  phlegmonous  erysipehis,  another  from 
exhaustion;  and  the  third,  in  nine  days,  in  whom  there  was  complete 
obstruction  at  the  time  of  the  operation;  and  in  whom  paracentesis 
abdominis  was  performed  immediately  after  the  colotomy;  acute  pleurisy 
being  the  immediate  cause  of  death.     Curling  has  performed  the  opera- 


216  DISEASES    OF   THE    EECniM    AND    ANUS. 

tion  eighteen  times  with  seven  fatal  results;  two  from  chloroform,  one 
from  already  existing  peritonitis,  another  from  peritonitis  arising  inde- 
pendently of  the  operation,  but  immediately  succeeding  it,  one  from 
pyaemia,  and  two  from  exhaustion,  one  on  the  sixth,  and  the  other  on 
the  twelfth  day.  Bryant  records  fifteen  operations  of  his  own,  four  for 
vesico-intestinal  fistula;  two  for  pelvic  tumor;  and  nine  for  stricture, 
cancerous  and  otherwise.  Of  these  latter,  one  lived  eighteen  months  in 
comfort,  dying  at  last  supposably  of  cancer  of  the  liver;  two  lived  two 
and  four  months  respectively;  one  lived  thirteen  days,  and  two  three 
days;  in  these  cases  the  operation  having  been  undertaken  too  late  to 
prolong  life.  One  died  of  peritonitis  due  to  the  operation,  and  three 
were  alive  at  periods  varying  from  one  to  three  years. 

Bulteau'  has  collected  one  hundred  and  forty  two  cases  of  lumbar 
colotomy  from  the  statistics  of  Doliger,  Mason,  Hawkins,  and  Heath. 
Of  these  ninety-two  recovered  and  fifty  died.  These  figures  are  about 
the  same  as  those  reached  by  D'Erckelens.* 

These  figures  show  as  well  as  would  a  more  elaborate  collection  of 
eases  the  general  results  of  the  operation  itself,  the  dangers  which  attend 
it,  and  especially  the  danger  of  postponing  its  performance  till  the  patient 
is  at  the  point  of  death.  These  patients  sometimes  sink  with  unexpected 
rapidity  at  tiie  end,  and  when  seemingly  no  worse  than  for  weeks  before 
are  often  very  near  death.  In  my  own  experience  I  have  had  a  patient 
die  in  the  night  upon  whom  I  intended  to  operate  in  the  morning. 

Although  an  artificial  anus  is  justly  regarded  as  being  only  a  substi- 
tute for  death  itself;  and  although  many  patients  will  deliberately  choose 
the  latter  to  the  dangers  and  results  of  the  former;  it  is  astonishing  how 
comfortable  a  patient  may  be  with  one  where  the  retention  of  faeces  is 
good.  Bridge's  case,"  in  which  the  prostitute  followed  her  customary 
avocation  after  its  performance,  is  certainly  an  exceptionally  favorable 
one,  but  it  illustrates  what  may  be  done.  Still  we  have  AUingham's* 
testimony  that  "  tins  operation,  though  doubtless  it  may  prolong  life, 
should  not  be  resorted  to  without  due  consideration,  because  one  cannot 
fail  to  see  in  many  cases  the  remedy  proves  a  most  objectionable  one;  an 
opening  in  the  left  loin  through  which  the  faeces  escape  is  very  harassing 
and  nothing  but  a  great  desire  to  live  or  the  fear  of  immediate  death 
would  lead  me  to  submit  to  such  a  proceeding.  I  presume  after  years 
the  patients  get  used  to  the  discomforts  and  loathsomeness  of  their  condi- 
tion. My  patients  who  have  lived  long  seem  to  have  had  some  pleasure 
in  life;  indeed,  two  women  Avere  married  after  the  operation;  but  with  all 
that  I  entertain  repugnance  to  the  operation  greater  than  I  formerly  used, 

'  De  Tocclusiou  intestinale  au  point  du  vue  du  diagnostic  et  du  traitement. 
These  de  Paris.  1 878. 

-  Arch,  fur  Klin.  Chirurg.,  vol.  xxiii.,  1  Heft,  1878. 

'  Loc.  cit. 

*  Loc.  cit ,  p.  253. 


N0N-M\L1GNANT   STRICTURE   OF   THE   RECTUM.  217 

and  latterly  have  mostly  performed  it  as  a  last  resource  or  for  total 
obstruction." 

The  operation  has  already  been  described.  A  free  discharge  of  faeces 
may  follow  the  opening  of  the  bowel,  or  there  may  be  only  a  slight  escape 
of  fluid.  It  IS  better  for  the  patient  that  the  evacuation  should  be  post- 
poned till  the  edges  of  the  wound  have  become  agglutinated,  as  in  this 
way  the  danger  of  extravasation  is  diminished.  Morphine  should  be 
given  hypodermically  to  keep  the  bowels  as  quiet  as  possible  till  cicatriza- 
tion is  complete.  Only  the  simplest  dressings  and  perfect  cleanliness  are 
necessary  in  the  way  of  local  treatment.  The  sutures  may  be  left  in  till 
they  commence  to  cause  suppuration.  If  the  bowels  are  slow  to  empty 
themselves,  an  enema  may  be  administered,  or  a  scoop  used  through  the 
new  opening  and  a  purgative  may  be  given  by  the  mouth.  No  change  is 
necessary  in  the  ordinary  diet  after  the  second  day.  The  patient  should  be 
kept  in  bed  for  two  or  three  weeks  till  cicatrization  is  complete,  and  then 
a  pad  must  be  arranged  to  cover  the  new  anus  and  prevent  leakage  of  faeces 
and  prolapse  of  the  mucous  membrane.  Bryant  says  some  of  his  patients 
have  found  great  comfort  from  the  use  of  an  india  rubber  ball  with  one 
of  its  sides  cut  away  sufficiently  to  cover  the  new  opening.  It  holds  any 
little  faeces  which  may  come  away,  besides  preventing  the  escape  of  flatus 
and  serving  as  a  pad. 

Annoying  prolapse  is  not  as  apt  to  occur  with  the  oblique  incision  as 
with  the  old  vertical  one,  nevertheless,  it  may  be  expected  in  some  degree, 
and  the  patient  should  be  taught  to  exercise  the  greatest  regularity  in  re- 
lieving the  bowels  early  in  the  morning. 

Should  faeces  pass  the  artificial  opening,  as  they  are  apt  to  do,  they 
must  be  removed  by  enemata,  for  a  very  small  quantity  will  cause  great 
pain  and  a  constant  demand  for  their  removal. 

It  will  at  once  be  seen  that  the  treatment  of  a  stricture  high  up  in  the 
rectum  or  in  the  sigmoid  flexure  must  be  conducted  on  entirely  differ- 
ent principles  from  one  within  reach  of  the  finger.  In  the  latter  case, 
the  disease  itself  may  be  directly  attacked  with  the  bougie  or  the  knife; 
in  the  former,  both  are  nearly  out  of  the  question,  and  the  surgeon  is 
in  reality  limited  to  attempts  at  warding  off  the  natural  effects  of  the 
malady;  in  other  words  to  preventing  the  occurrence  of  intestinal 
obstruction,  and  forming  an  artificial  outlet  for  the  contents  of  the 
bowel  when  obstruction  is  threatened.  The  medicinal  means  of  pre- 
venting obstruction,  and  of  overcoming  it  when  actually  impending, 
have  already  l)een  referred  to  in  the  chapter  on  prolapse  and  invagina- 
tion. In  cases  of  cancerous  disease,  attention  must  be  given  to  cleanliness 
as  well  after  as  before  the  operation,  and  this  Is  best  secured  by  frequent 
injections  of  an  unirritating  disinfectant,  as  the  permanganate  of  potash. 
In  cases  of  non-malignant  ulceration,  the  diseased  surface  may  be  treated 
after  the  operation  as  before. 


218  DISEASES   OF   THE    RECTUM    AND    ANUS. 


CHAPTER  XI. 

CANCER. 

General  Characters  of  Malignant  as  Distinguished  from  Benign  Growths. — Malig- 
nant, Semi-Malignant,  and  Benign  Adenoma. — Encephaloid. — Colloid. — 
Melanotic  Cancer. — Osteoid  Cancer. — Age  at  which  Cancer  occurs. — Symp- 
toms.— Diagnosis. — Treatment. — Excision:  History  and  Results  of  Operation. 
— Conclusions  Regarding  Excision. — Modes  of  Performing  the  Operation. — 
Excision  of  Cancer  of  the  Sigmoid  Flexure. — Palliative  Treatment. 

In  a  general  Avay  it  is  undoubtedly  true  that  new  growths  in  the  rec- 
tum, when  benign,  increase  slowly,  tend  to  grow  away  from  the  wall  of 
the  bowel,  to  form  pedicles  for  themselves,  and  to  project  into  the  calibre 
of  the  canal,  to  remain  movable,  and  not  to  involve  surrounding  parts; 
while  with  cancerous  formations  the  tendency  is  just  the  opposite.  In 
this  way  the  diagnosis  between  a  benign  polyp  and  a  cancerous  nodule  in 
the  wall  of  the  rectum  is  generally  easy. 

But  there  is  a  class  of  tumors  which  occupy  the  border  line  between 
the  benign  and  the  malignant,  in  which  the  dignosis  either  clinically  or 
with  the  micrscope  may  be  difficult  and  even  impossible.  In  fact  recent 
careful  study  of  these  rectal  tumors  goes  far  to  break  down  the  lines  be- 
tween the  varieties  which  are  usually  drawn,  and  Cripps,'  who  has  done 
such  careful  and  valuable  work  in  this  department,  is  inclined  to  group 
nearly  all  of  them  under  the  single  head  of  adenoma,  holding  that  all  are 
primarily  affections  of  the  glandular  element.  The  true  nature  of  the 
growths  may  perhaps  best  be  gleaned  from  a  comparison  of  Fig.  52  with 
Fig.  45,  the  latter  being  a  benign  polypus,  and  the  former  a  malignant 
growth,  but  both  being  adenomata. 

According  to  Cripps  the  names  malignant,  semi-malignant,  and 
simple  adenoid  will  cover  both  the  benign  and  cancerous  growths  of  this 
part  of  the  body,  except  possibly  the  form  of  colloid.  Generally,  but  not 
always,  it  is  possible  to  distinguish  between  them  both  clinically  and 
microscopically. 

After  speaking  of  the  innocent  growth  which  is  soft,  has  a  fairly 

'  Cancer  of  the  Rectum,  London,  1880.  Also  Adenoid  Disease  of  the  Rectum. 
Trans.  Path.  Soc.  of  London,  1881. 


CANCER.  219 

marked  pedicle,  and  projects  into  the  cavity  of  the  bowel,  he  says:  "  In 
the  more  malignant  varieties,  the  new  growth  frequently  spreads  as  a 
thin  layer  between  the  muscular  and  mucous  coats.  In  this  form  it  often 
occupies  several  square  inches  of  the  bowel,  while  its  thickness  does  not 
exceed  a  quarter  of  an  inch.  At  first  the  mucous  membrane  lies  intact 
over  such  a  layer,  but  eventually  it  gives  way  by  ulceration.  This  ulcer- 
ation sometimes  begins  at  more  than  one  point,  so  that  the  mucous  mem- 
brane becomes  honeycombed,  and  portions  of  the  subjacent  growth  may 
even  sprout  through  it.  The  destructive  process  not  only  destroys  the 
mucous  membrane  over  the  surface  of  the  growth,  but  after  a  while  the 
new  growth  is  itself  destroyed  by  ulceration.  While  destruction  is  pro- 
ceeding toward  the  centre,  the  growth  is  advancing  towards  the  circum- 
ference. In  this  way  a  crater-like  muss  of  disease  is  produced,  the  centre 
of  which  consists  of  dense  fibrous  tissue  belonging  to  the  muscular  coat 
of  the  bowel,  which  appears  for  long  to  resist  the  ulcerative  process.     The 


Fig.  32.— Cancer  of  the  rectum— Mali^ant  adenoma  (Stimson). 

margin  of  the  crater  consists  of  the  mucous  membrane  of  the  bowel, 
heaped  up  by  tiie  extending  growth  beneath  it,  tucking  it  over  in  such  a 
manner  as  to  overlap  the  healthy  membrane.  The  border  is  at  times  so 
irregular  as  to  represent  a  series  of  nodules  rather  than  a  continuous 
line." 

Stimson'  has  also  made  a  careful  study  of  these  growths.  He  says: 
"  If  it  is  admitted  that  cancer  of  the  rectum  is  essentially  a  glandular  or 
epithelial  affection,  one  having  its  origin  in  the  mucous  membrane,  the 
borders  of  the  growth,  as  being  the  freshest,  most  recent  portions, 
must  be  examined,  as  in  carcinoma  of  other  organs,  for  evidences  of 
primary  changes  and  mode  of  development.  These  changes  consist  of 
hypertrophy  of  the  mucosa  by  hypertrophy  and  hyperplasia  of  its  epithe- 
lial elements,  together  with  an  abundant  development  of  embryonal 
connective  tissue  between  the  tubules.  They  are  the  same  as  those  found 
in  a  variety  of  neoplasm  of  recognized  benign  character  known  as  polyp 

'  A  Contribution  to  the  Study  of  Cancer  of  the  Rectum.  Archives  of  Medi- 
cine, August,  1879. 


220  DISEASES    OF    THE    KECTUM    AND    ANUS. 

of  the  rectum  or  potypoid  adenoma.  The  formation  of  a  pedunculated 
growth  with  a  tendency  to  isolation  in  the  one  case,  and  of  a  flat  growth 
with  a  tendency  to  spread  laterally  and  into  the  underlying  tissue  in  the 
other,  may  be  explained  partly  by  mechanical  causes  and  partly  bv 
the  degree  of  intensity  of  the  changes  in  the  submucous  connective 
tissue.  If  the  primary  change  occupies  a  limited  area  upon  a  natural 
fold  of  the  mucous  membrane,  and  if  the  muscularis  mucosae  remains 
unbroken  until  the  young  embryonal  cells  produced  below  it,  in  conse- 
quence of  the  neighboring  irritation,  have  had  time  to  develop  into  adult 
fibrous  tissue,  the  natural  retraction  of  this  new  tissue  narrows  the  base 
of  the  fold,  giving  it  at  once  a  polypoid  form  and  opposing  by  its  greater 
density  a  stronger  barrier  to  the  extension  of  the  epithelial  formation  in 
this  direction.  The  pedicle  once  formed,  the  neoplasm  increases  in  the 
direction  open  to  it,  that  is,  into  the  lumen  of  the  canal  in  all  its 
diameters,  and  the  dragging  to  which  it  is  subjected  by  the  constantly 
recurring  passage  of  the  faeces  lengthens  its  pedicle  and  tends  towards 
its  final  separation. 

"  On  the  other  hand,  if  a  broader  area  is  occupied  by  the  primary 
change,  or  if  the  processes  are  more  intense  and  rapid,  the  pedunculation 
is  absent  or  less  perfect,  and  the  epithelial  growths  of  the  mucosa  break 
through  immediately,  or  after  an  interval  spent  in  overcoming  the 
greater  resistance  offered  by  the  partial  pedunculation,  into  the  sub- 
mucous tissue.  Once  established  in  that  region  the  spread  of  the  disease 
is  easy,  and  its  ultimate  generalization  a  question  only  of  time. 

**  The  second  and  final  barrier  to  generalization  is  presented  by  the 
muscular  coat  of  the  intestine,  but  it  is  a  barrier  in  which  are  many  gaps, 
large  ones  along  the  lines  of  the  vessels,  and  innumerable  small  ones  in 
the  fine  meshes  of  connective  tissue  which  separate  the  muscular  bundles 
and  are  continuous  with  the  submucous  tissue  on  one  side  and  the  para- 
rectal tissue  on  the  other.  Here,  too,  the  intensity  of  the  process 
materially  affects  the  rapidity  of  its  extension,  for  if  the  proliferating 
connective  tissue,  which  is  most  easily  implicated  while  it  is  in  the 
formative  stage,  is  allowed  time  to  reach  its  full  development,  to  become 
fibrous,  it  forms,  as  it  were,  a  second  line  of  defence  capable  of  offering  a 
certain  resistance  after  the  first  line  has  been  carried." 

With  a  full  appreciation  of  the  importance  of  the  conclusions  which 
Cripps  has  reached,  it  may  still  be  well,  in  a  work  of  this  kind,  to  call 
attention  to  some  of  the  clinical  characters  of  some  of  the  different 
forms  of  malignant  disease  as  found  in  this  part  of  the  body. 

Of  all  the  varieties  of  true  cancer,  the  one  most  frequently. met  with 
is  epithelioma,  and  this  presents  itself,  here  as  elsewhere  in  the  body, 
under  two  forms  distinguishable  with  the  microscope  and  clinically. 
The  first  (cancroid,  lobulated  epithelioma)  contains  the  characteristic 
onion-like  nests  of  squamous  epithelium,  and  is  the  same  form  so 
commonly  seen  in  the  lip,  though  rarely  about  the  anus.     It  has  its  point 


CANCKB.  221 

of  origin  at  the  anus,  and  not  within  the  rectum,  and  begins  as  a  hard, 
dry,  warty  nodule.  It  is  slow  in  progress,  covered  at  first  with  firm  epi- 
dermis, and  only  begins  to  ulcerate  late  in  its  course.  It  seldom  spreads 
far  up  the  rectum,  but  tends  rather  to  involve  the  integument,  which  it 
may  destroy  to  an  extent  similar  to  that  sometimes  seen  in  the  same 
variety  of  disease  about  the  face.  In  the  other  variety  (cylindrical  epi- 
tlielioma),  the  cells  are  columnar,  and  the  growth  resembles  in  minute 
structure  the  mucous  membrane  from  which  it  springs.  This  variety,  on 
the  contrary,  chooses  the  rectum  proper  for  its  development,  and  is  found 
above  the  internal  sphincter.  It  is  easily  distinguished  from  the  former, 
but  not  so  easily  from  a  scirrhus  which  has  begun  to  ulcerate.  It  is 
softer  than  the  other,  more  vascular,  and  therefore  more  prone  to  bleed 
and  undergo  extensive  degeneration  and  ulceration;  and  it  rapidly  infil- 
trates surrounding  tissues.  Early  in  its  course  it  is  movable  on  the 
subjacent  tissues,  but  it  is  seldom  seen  by  the  surgeon  at  this  stage.  At 
a  later  period  it  presents  itself  as  a  soft,  friable  mass  seated  on  a  hard, 
infiltrated  base;  ulcerated  in  spots,,  the  edges  of  the  ulcers  being  hard 
and  raised.  At  this  stage  the  growth  will  yield  on  pressure  the  well- 
known  cancer  juice  containing  cells  and  nuclei,  and  it  may  be  difficult  to 
distinguish  it  from  a  tumor  which  began  in  the  submucous  tissue  as  a 
hard  mass,  and  subsequently  underwent  degeneration. 

Next  to  epithelioma,  scirrhus,  or  hard  cancer,  is  the  variety  most 
frequently  met  with  in  the  rectum.  It  arises,  not,  like  epithelioma,  in 
the  mucous  membrane,  but  in  the  submucous  connective  tissue;  there- 
fore in  the  early  stages  of  its  growth  tlie  membrane  is  found  normal  and 
movable  over  the  hard  mass  beneath.  When  cut  into  it  shows  the 
characteristic,  raw  potato-like  hardness  of  scirrhus,  and  there  is  no  dis- 
tinct line  of  demarcation  between  it  and  the  adjacent  tissues.  From  the 
original  tumor  are  often  seen,  and  sometimes  felt,  hard  fibrous  bands 
spreading  out  in  various  directions,  generally  longitudinally  in  the  bowel 
— the  processes  or  claws  from  which  cancer  takes  its  name.  These 
tumors  may  soften  down  in  parts  and  slough  or  ulcerate  away.  When 
ulceration  has  begun,  a  cavity  with  an  irregular  outline  is  formed  in  the 
midst  of  the  hard  cancer  tissue,  from  which  issues  a  fetid  discharge 
mixed  with  more  or  less  blood  and  pus.  Although  a  large  part  of  the 
growth  may  die  in  this  way  and  be  discharged,  the  steady  increase  in  the 
disease  is  not  checked.  Indeed,  the  growth  often  seems  to  be  most  rapid 
in  the  bed  of  the  part  which  has  been  destroyed. 

This  form  of  cancer  is  said  to  be  most  apt  to  show  itself  first  on  the 
anterior  wall  of  the  rectum,  near  the  prostate,'  and  "to  increase  most  on 
the  side  of  the  chief  arterial  supply,  and  in  that  toward  which,  by 
lymphatics  and  veins,  its  constituent  fluids  most  easily  filter."*    It 

'  AUinghani,  Molliere. 

*  Moore,  see  Bryant's  Surgery. 


222  DISEASES    OF    THE    KECTUM    AND    ANUS. 

spreads  by  infiltrating  all  the  adjacent  parts,  eventually  involving  all  the 
coats  of  the  bowel,  and  extending  both  in  surface  and  in  thickness  till, 
instead  of  appearing  as  a  hard,  movable  spot  under  the  mucous  mem- 
brane, it  involves  a  great  part  or  the  whole  of  the  circumference  of  the 
rectum,  inclosing  it  in  a  dense,  contracting  sheath.  The  hardness  and 
contractility  of  this  form  of  disease  are  the  chief  clinical  facts  upon  which 
a  diagnosis  rests;  and  yet,  leaving  out  of  consideration  the  history  of  the 
case,  it  will  often  be  impossible  to  distinguish  between  the  gross  appear- 
ances of  scirrhus  and  those  of  simple  fibrous  stricture.  I  have  now  under 
treatment,  at  the  Infirmary  for  Diseases  of  the  Rectum,  a  case  of  stric- 
ture which  I  believe  to  be  dysenteric  in  origin,  in  which  the  extent  of  the 
disease  is  fully  as  great  as  in  any  hard  cancer  I  have  ever  met  with,  and 
yet  which  has  been  eighteen  years  in  developing. 

Encephaloid  has  its  primary  seat  in  the  glandular  tissue  of  the 
mucous  membrane.  It  is  inclosed  in  a  capsule  of  connective  tissue, 
from  the  internal  surface  of  which  spring  trabeculae  which  divide  the 
mass  into  lobules.  On  section,  it  may  be  comparatively  firm  or  nearly 
fluid,  and  almost  white  or  stained  red  with  blood.  It  is  often  very 
vascular;  large  vessels  may  sometimes  be  seen  on  its  surface,  and  large 
blood  extravasations  may  be  found  in  its  interior.  The  name  fungus 
haematodes  has  been  applied  to  a  variety  of  this  disease  in  which,  after 
the  capsule  has  burst,  the  mass  has  protruded.  The  material  composing 
it  may  resemble  brain  tissue  (from  which  it  is  named),  or  it  may  bo  more 
spongy  and  shreddy,  like  placenta.  On  squeezing  a  section  of  the  tumor, 
a  large  amount  of  juice  may  be  obtained,  and  this,  when  thrown  into  a 
vessel  of  water,  is  uniformly  diffused  through  it,  giving  it  a  milky  hu-.'. 
This  is  given  by  Paget  as  an  exceedingly  valuable  rough  test  of  the 
nature  of  the  gi'owth.  These  cancers  are  rapid  in  their  increase,  and 
may  attain  an  immense  size,  fairly  filling  the  pelvis.  They  quickly 
affect  the  neighboring  lymphatics,  and,  when  enucleated,  speedily  recur. 
The  results  of  removal  are,  however,  particularly  favorable  for  a  short 
time,  as  shown  by  the  immediate  improvement  in  the  general  condition 
of  the  patient,  and  the  disappearance  of  the  cancerous  cachexia.  The 
extreme  softness  of  the  tumor,  and  the  deceptive  sense  of  fluctuation 
imparted  to  the  finger,  may  cause  a  mistake  in  diagnosis,  which  may  be 
avoided  by  the  use  of  the  aspirator,  or  even  the  hypodermic  syringe. 
When  the  fluid  thus  obtained  is  examined  under  the  microscope,  it  will 
be  found  to  contain  cells  and  nuclei,  with  more  or  less  blood. 

In  colloid  cancer  (alveolar  sarcoma),  the  structure  is  essentially  the 
same  as  in  the  last  variety,  except  that  the  alveolar  meshes  are  filled  with 
a  mucous,  glue-like  material,  which  in  its  most  natural  state  is  glistening, 
translucent,  and  pale-yellow.  This  variety  of  cancer  has  its  origin  in  the 
follicles  of  Lieberkiihn,  or  the  crypts  which  surround  the  rectum.  It 
is  not  very  rare  in  this  part,  and  appears  in  the  shape  of  large,  lobulated, 
fungus-like  tumors,  which  are  soft  and  easily  broken  down.     Under  the 


CANCEB.  223 

mioroscope,  the  mucous  contents  of  the  alveoli  will  be  seen  to  contain 
cells  of  various  forms,  the  most  characteristic  being  large,  round,  and 
flat,  with  a  nucleus  and  concentric  laminae.  Tlie  growth  rapidly  infil- 
trates the  surrounding  tissues,  and  secondary  deposits  will  often  be 
found  in  the  neighborhood  of  the  original  mass,  the  whole  tending  to 
undergo  cystic  degeneration.  The  malignancy  of  these  tumors  varies  in 
degree,  some  of  them  being  comparatively  benign;  they  do  not  always 
recur  after  removel,  nor  do  they  readily  infect  the  lymphatics  and 
viscera,  being  in  this  respect  about  on  a  par  with  epithelioma.  The  term 
colloid  is  used  without  much  exactness,  being  applied  to  almost  any 
growth  which  consists  in  part  of  large,  cellular  spaces  filled  with  glue- 
like material.  The  following  description  of  a  case  illustrates  very  per- 
fectly the  general  characteristics  of  colloid; 

Case  XXII. — "  Tiie  patient  was  an  old  woman,  and  the  case  was 
peculiar,  in  that  the  colloid  material  Avas  contained  in  cysts  of  various 
sizes,  pressed  firmly  one  against  the  other,  so  that  the  disease  might  be 
called  multiple  cystic  colloid  degeneration.  The  anus  was  surrounded , 
with  a  large  number  of  tumors  of  unequal  size,  of  which  several,  larger 
than  the  rest,  were  surmounted  by  smaller  ones  in  such  a  way  that  the 
anus  occupied  the  bottom  of  an  extremely  deep  infundibulum.  Two 
superficial  ulcerations  were  to  be  seen  at  the  margin  of  the  anus.  The 
finger  recognized  at  a  short  distance  above  the  anus  an  ulceration  in  the 
form  of  a  zone,  wliich  was  deep,  had  destroyed  all  the  thickness  of  the 
rectum  in  a  part  of  its  circumference,  and  communicated  with  fistulous 
tracks,  which  penetrated  into  the  substance  of  the  diseased  skin  adjacent 
to  the  anus. 

The  degeneration,  which  had  given  the  rectum  an  enormous  thick- 
ness, ceased  abruptly  nine  or  ten  centimetres  from  the  anus.  Immedi- 
ately above,  the  rectum  presented  considerable  hypertrophy  in  the 
muscular  layer.  This  affection,  which  had  all  the  characters  of  colloid 
degeneration,  presented  an  arrangement  in  its  upper  two-thirds  which  I 
had  never  before  met  with,  and  whicli  I  will  try  and  describe.  Let  one 
imagine  a  number  of  acephalocysts  of  unequal  size  (some  of  them  as  large 
as  pigeons'  eggs)  squeezed  firmly  one  against  the  other,  and  held  m  a 
fibrous  network,  and  one  will  have  an  exact  idea  of  the  change.  Only 
these  were  not  acephalocysts.  The  covering  of  each  cyst  was  fibrous, 
very  thin,  and  yet  very  strong ;  the  matter  contained  in  them  exactly 
resembled  currant  jelly,  on  the  surface  of  which  had  been  deposited  a 
cretaceous  matter  exactly  similar  to  that  which  sometimes  covers  the 
excrement  of  l)irds.  This  cretaceous  matter  contained  calcareous  con- 
cretions. In  the  centre  of  the  jelly-like  substance,  two  or  three  blood- 
vessels were  to  be  seen,  similar  to  those  which  form  in  a  hen's  egg — 
vessels  without  walls,  ending  in  an  enlargement  of  one  extremity. 

The  fibrous  network  in  the  midst  of  which  these  cysts  were  inclosed 
was  evidently  made  up  of  the  transformed  coats  of  the  rectum.     I  could 


224  DISEASES    OF   THE    RECTUM    AND    ANUS. 

recognize  the  longitudinal  fibres  of  the  rectum.  There  was  also  adipose 
tissue,  an  evident  proof  that  the  degeneration  had  not  only  invaded  the 
rectum,  but  had  developed  at  the  expense  of  the  adipose  tissue  of  the 
pelvis. 

The  lower  third  of  the  rectum  presented  no  sign  of  a  cyst,  but  an 
areolar  tissue,  with  fibrous  meshes,  which  occupied  all  the  circumference 
of  the  anus;  this  tissue  was  filled  like  a  sponge  with  colloid  matter, 
which  could  easily  be  pressed  out,  and  the  tissue  itself  was  approaching 
erosion  or  ulceration.  The  areolar  and  gelatiniform  degeneration 
appeared  to  me  to  penetrate  into  the  thickness  of  the  skin  of  the  anal 
region;  while  an  extremely  thin,  almost  epidermic,  pellicle  had  resisted 
and  covered  the  swellings  on  its  surface.  In  the  vicinity  of  the  circular 
ulceration  of  the  rectum,  the  colloid  matter  had  not  undergone  degenera- 
tion, only  it  was  permeated  by  an  increased  number  of  blood-vessels. 
Behind  the  rectum  was  a  colloid  alveolar  mass,  all  the  areolae  of  which 
contained  blood-vessels.  This  mass  had  evidently  been  formed  at  the 
expense  of  the  circum-rectal  adipose  tissue.'" 

Cruveilhier  draws  this  distinction  between  colloid  and  encephaloid. 
The  colloid  degeneration  is  not  susceptible,  as  is  the  encephaloid,  of 
inflammatory  action  producing  gangrene;  moreover,  if  the  sanguineous 
centres  are  not  absolutely  foreign  to  it,  it  is  certain  that  they  are  incom- 
parably rarer  in  colloid  than  in  the  cancerous  degeneration,  properly  so 
called,  where  effusions  of  blood  are  so  often  met  with — apoplectic  centres 
sometimes  so  large  as  to  conceal  the  true  nature  of  the  morbid  tissue. 

Colloid  alveolar  degeneration  shows  only  one  mode  of  destruction — 
by  encroachment  in  successive  layers;  this  encroachment,  sometimes 
rapid  when  it  occurs  in  the  alimentary  canal,  permits  of  the  re-establish- 
ment of  the  flow  of  faeces,  temporarily  interrupted  by  the  undefined  and 
often  very  rapid  increase  in  the  degenerated  parts;  so  that,  to  the 
gravest  signs  of  fecal  retention,  there  sometimes  succeeds  a  more  or  less 
rapid  separation,  with  or  without  diarrhoea." 

Melanotic  carcinoma,  or  black  cancer,  is  by  some  classed  among  the 
true  cancers,  and  by  others  among  the  sarcomata.  It  belongs  to  the 
class  of  soft  or  medullary  cancers,  and  its  distinguishing  feature  is  the 
development  of  pigment.  Whatever  may  be  said  of  the  microscopic 
characters  of  melanoma,  it  is  clinically  a  very  malignant  growth,  running 
a  very  rapid  course,  and  very  likely  to  become  generalized.  Its  clinical 
history,  as  relates  to  the  rectum,  is  to  be  studied  from  ten  cases  only, 
which  have  been  given  in  full  in  an  exhaustive  study  by  Nepveu,  read 
before  the  Societe  de  Chirurgie  (1880).^     The  cases  are  reported  by  the 


'  Cruveilhier,  Traite  d'Anatomie  Path.  Gren.,  t.  v.,  p.  67. 

'Ibid.,  p.  69. 

»  "  Memoires  de  Chirurgie,"  Paris,  1880. 


CANCEE.  225 

following  observers:  Schilling,'  Kopp,*  Moore,'  Maier/ Virchow,*  Ash- 
ton,*  Gross/  Meunier,*  Gussenbauer,"  and  Nepveu." 

From  the  six  of  these  cases  which  are  reported  with  an  approach  to 
completeness,  several  facts  of  interest  are  to  be  gathered.  The  age  of  all  of 
the  patients  was  advanced,  ranging  between  forty-five  and  sixty-four  years. 
Five  were  in  men,  one  only  in  a  woman.  In  the  microspic  examinations 
which  were  made  in  five  of  the  cases,  the  tumor  is  in  every  case  described 
as  a  sarcoma.  There  is  nothing  in  the  symptomatology  to  distinguish 
this  form  of  disease  from  others,  except  that  in  one  case  the  stools  were 
colored  black  from  mixture  with  the  pigment — a  point  which  might  aid 
in  diagnosis,  were  the  tumor  so  high  up  as  to  be  out  of  sight.  In  rectal 
examinations  it  was  also  noticed  that  the  finger  was  colored  in  the  same 
way.  The  location  of  the  disease  was  once  in  the  sigmoid  flexure,  twice 
in  the  rectum  above  the  sphincter,  and  four  times  at  the  anus.  The 
size  of  the  growth  was  generally  considerable,  surrounding  the  bowel  and 
projecting  into  its  cavity;  sometimes  it  was  firm  enough  to  cause  tight 
stricture,  at  others  ulcerated  and  broken  down  in  parts.  The  course  of 
the  disease  is  marked  by  secondary  deposits  in  the  adjacent  glands  or  in 
the  viscera,  while  the  original  growth  my  spread  in  neighboring  organs, 
and  by  ulceration  cause  a  foul  discharge  mixed  with  blood  and  pigment. 
To  these  may  be  added  the  usual  signs  of  incontinence  and  obstruction. 
The  duration  of  the  disease  in  no  case  exceeded  three  years,  but  it  was 
generally  fatal  in  a  much  shorter  time.  The  diagnosis  is  easy  if  the 
gi'owth  can  be  seen,  and  is  sometimes  assisted  by  the  secondary  black  de- 
posits. In  four  cases  the  tumor  was  removed,  but  in  none  was  the  return 
long  delayed. 

Osteoid  Cancer. — Either  a  sarcoma  or  a  carcinoma  in  any  part  of  the 
body  may  become  ossified,  and  hence  pathologists  speak  of  osteo-sarcoma 
and  osteo-carcinoma.  It  is  rare  that  such  a  formation  is  found  in  any 
structure  except  bone  or  periosteum;  and  there  seems  to  be  but  one  case 
on  record  of  bone-cancer  of  the  rectum,  which,  because  of  its  great 
rarity,  I  will  quote  in  part: 

Case  XXIII. — The  preparation  was  removed  from  the  body  of  a  lady, 

'  Mentioned  by  Eiselt,  obs.  v.,  Prag.  Viertelj.,  Bd.  70  u.  76. 
'  "  Denkwurdigkeiten  in  der  &rztUchen  Praxis,"  Bd.  iv.,  Frankfort,  1838,  pp. 
805-313. 

»  Medical  Times,  March,  1857. 

*  Berichte  tiber  die  Verhandlungen  der  Naturforschenden  Oesellschaft  zu  Frei- 
burg, 1858,  No.  30,  p.  516, 

*  "  Pathologie  desTumeurs,"  Paris,  1867,  t.  ii.,  p.  281,  note. 

*  Ashton,  T.  J.,  "Prolapsus,  Fistula  in  Ano,"  etc.,  3d  ed.,  London,  1870,  p.  162. 
'  "  System  of  Surgery."  Phil.,  1872,  vol.  ii.,  p.  589. 

»"BuIl.  de  laSoc.  Anat.  de  Paris,"  1875,  p.  792. 

*"Ueber  die  Pigmentbildung  in  melanotischen    Sarcomen  und  einfachen 
Melanomen  der  Haut."    Virchow's  Arch.  f.  path.  Anat.  u.  Phys.,  Ixiii.,  1875. 
'*'0p.  cit. 
15 


226  DISEASES    OF   THE   RECTUM    AND    ANUS. 

aged  about  fifty-four,  who  died  January  18tli,  1869,  under  the  care  of  Mr. 
Collambell,  of  Lambeth.  The  history  of  the  case  pointed  to  the  existence 
of  disease  in  the  rectum  for  about  twenty  years  (during  which  time  she 
had  occasionally  complained  of  pain,  irregularity  of  the  bowels,  and  a 
dischargeof  blood  and  mucus).  .  .  .  The  specimen  includes  the  whole  pel- 
vic viscera.  The  rectum  is  laid  open  posteriorly,  but  rather  on  the  right 
side,  and  shows  a  cancerous  mass  projecting  into  its  interior  at  a  distance 
of  about  four  or  five  inches  from  the  anus.  The  principal  mass,  of  about 
the  size  of  a  walnut,  is  situated  directly  at  the  back,  and  occupies  nearly 
the  whole  calibre  of  the  rectum,  but  the  disease  involves,  more  or  less, 
the  entire  circumference  of  the  intestine  upon  a  level  rather  above  the 
larger  mass.  A  small  opening,  large  enough  to  admit  a  goose-quill,  is 
found  in  the  sigmoid  flexure,  about  twelve  inches  above  the  cancerous 
growth,  and  communicates  with  a  circumscribed  abscess  cavity  within 
the  peritoneum,  above  the  pelvic  viscera,  and  behind  the  pubes,  and  this 
again  communicates  with  the  rectum  immediately  below  the  obstruction. 
At  the  time  of  the  post-mortem  this  peritoneal  abscess  contained  very 
little  fluid,  but  what  there  was  was  pus  discolored  with  fecal  matter. 
There  is  also  a  large,  foul,  burrowing  abscess,  situated  in  the  submucous 
tissues,  almost  completely  surrounding  the  rectum  at  the  seat  of  disease, 
communicating  freely  with  its  cavity  and  directly  continuous  with  the 
intra-peritoneal  abscess. 

When  first  laid  open,  the  surface  of  the  cancer  generally  presented  a 
nodulated,  red  appearance,  but  the  larger  or  posterior  mass  was  rough- 
ened in  its  lower  half  by  numerous  sharp  spicules  of  bone  which  pro- 
jected from  its  surface.  The  cut  surface  showed  the  growth  involv- 
ing the  thickened  muscular  coat  as  a  hard,  contracting  mass  and  from  its 
base  firm  fibrous  bands  ramified  into  the  neighboring  fat,  just  as  from 
the  base  of  an  ordinary  scirrhous  tumor.  That  portion  which  pro- 
jected into  the  cavity  of  the  rectum  was  softer,  and  its  lower  part  was 
occupied  throughout  by  numerous  spicules  of  true  bone.  On  the  sur- 
face, the  softer  structures  having  sloughed  away,  the  bony  constituents 
were  exposed.  The  growth  did  not  extend  to  the  sacrum,  which  was 
perfectly  healthy,  and  the  other  bones  of  the  pelvis  were  also  free 
from  disease. 

The  other  viscera  were  examined  and  appeared  healthy.  The  lym- 
phatic glands  were  not  carefully  examined,  but  in  the  parts  wliich 
were  removed  there  was  no  glandular  enlargement  to  be  found.  The 
ulceration  in  the  sigmoid  flexure  seemed  to  be  of  a  simple  character; 
there  was  no  evidence  of  malignant  deposit  elsewhere  than  in  the  ob- 
structed portion  of  the  rectum. 

On  examining  the  growth  in  the  rectum  it  was  found  to  be  firm  in 
the  deeper  parts,  where  it  involved  mucous  and  submucous  tissues,  but, 
nearest  to  the  surface,  where  the  spicules  of  bone  were  evident,  it  had 
the  appearance  and  character,  to  the  naked  eye,  of  a  fibro-fatty  stnic- 


CANCEE.  227 

ture.  In  the  deepests  jmrts,  however,  where  it  was  firmest,  it  had  not 
any  very  great  hardness.  The  parts  involved  in  the  ossification  lay 
vposed  in  the  rectum,  and  seemed,  from  their  shreddy,  softened  appear- 
ance, to  have  been  recently  sloughing.  Upon  section,  a  quantity  of 
juice  was  readily  obtained,  and  showed  under  the  microscope  an  immense 
number  of  free  nuclei  and  cells  of  all  shapes  and  of  variable  sizes, 
though  the  greater  number  were  elongated  or  oval,  and  about  half  the 
size  of  the  columnar  epithelium  of  the  neighborhood.  There  was  a 
large  quantity  of  molecular  matter  and  oil,  and  the  nuclei  were  indistinct. 
The  solid  portion  of  the  growth  was  composed  of  cellular  and  muscular 
structures  imbeded  in  a  granular  matrix.  Bands  and  fibres,  composed 
almost  altogether  of  nuclei,  ramified  in  the  growth,  and  could  be  traced  as 
continuous  with  the  osseous  portions.  It  appeared  that  the  nuclei 
became  darker,  granular,  and  harder  in  outline  as  the  examination  was 
carried  toward  the  ossified  parts;  the  intervening  matrix  became  more 
fibrous,  and  the  processes  of  bone  branched  out  into  this.  The  bony 
spicules  contained  numerous  lacunae,  whose  size  was  about  that  of  the 
ordinjiry  nuclei  of  the  growth.  They  were  of  various  forms,  generally 
branching,  and  were  arranged  with  no  regularity,  but  in  the  manner 
usually  found  in  adventitious  bony  deposits  in  tumors.  The  matrix  was 
granular. 

The  interest  of  this  case  lies  chiefly  in  the  fact  of  bone  being  found 
ramifying  through  parts  of  the  structure;  and  that  this  bone  was 
tlie  result  of  ossification  of  the  scirrhous  growth  seems  evident  from  the 
manner  in  which  it  could  be  traced  under  the  microscope.  That  it  was 
not  an  original  formation  apart  from  the  scirrhus  must  be  admitted,  for 
its  histological  characters  show  its  definite  relation  to  the  elements  of  the 
tumor,  the  lacunae  replacing  the  nuclei,  and  the  rest  of  the  bone  occupying 
the  place  of  the  intervening  matrix.  And  a  primary  bone  tumor  in  this 
position  is  difficult  to  imagine.  The  occurrence  of  true  bony  deposit  in 
medullary  tumors  is  not  altogether  infrequent;  but  then  it  is  found  in  the 
deeper  parts,  and  is  almost  always  in  connection  with  some  bone.  In 
scirrhous  growths,  however,  I  do  not  find  any  mention  of  ossification 
occurring,  except  where  starting  from  bone.  I  have  no  history  of  any  case 
of  any  kind  of  tumor  of  the  rectum  in  which  bone  formed  an  element  of 
a  primary  growth.' 

These  are  the  rarer  forms  of  cancerous  disease  in  the  rectum  and  their 
recognitition  presents  little  difficulty.  Most  malignant  growths  are 
included  under  Cripps's  classification  of  adenoma  or  under  the  older 
terms  of  epithelioma  and  scirrhus.  Hecker'  found  twenty-one  cases  of 
epithelioma  in  thirty-four  cases  of  cancer.  Cripps  says,  **  I  have  failed 
to  discover  ''  (in  the  rectum)  "  any  growths  or  tumors  consisting  entirely 

'  Wagstaffe,  '•  Trans,  of  the  Path.  Soc.  of  London,"  vol.  xx.,  p.  176. 
« Schmidt's  Jahrbucher,  1870. 


228  DISEASES   OF   THE   RECTUM   AND    ANUS. 

of  the  characteristic  structure  which  pathologists  designate  as  scirrhus  or 
medullary  cancers,  or  as  belonging  to  the  various  varieties  of  sarcoma. 
Considering  the  eminence  of  many  careful  observers  who  have  applied 
such  names  to  these  growths,  it  would  be  quite  unjustifiable  to  assume 
that  such  distinctive  structures  never  form  the  entire  bulk  of  the  tumor; 
but  I  feel  bound  to  state  that  with,  perhaps,  a  more  than  average  oppor- 
tunity of  examining  such  growths  from  the  rectum,  I  have  been  unable 
myself  to  discover  tumors  composed  entirely  of  the  distinctive  features 
appertaining  to  these  diseases." 

Cancer  of  the  rectum,  like  cancer  elsewhere  in  the  body,  generally 
occurs  in  middle  life  or  old  age.  There  are,  however,  some  interesting 
exceptions  to  this  rule.  Allingham  '  reports  a  case  of  encephaloid  in  a 
boy  of  seventeen,  under  his  own  care;  and  another  (variety  of  cancer  not 
stated)  under  the  care  of  Mr.  Gowland,  in  a  boy  not  thirteen  ;  Mayo  *. 
speaks  of  one  at  the  age  of  twelve,  and  Godin "  of  one  at  fifteen  years ;  and 
Quain*  quotes  one,  reported  by  Busk,  at  sixteen.  After  the  age  of 
twenty  the  cases  increase  rapidly  in  number.  With  regard  to  the  relative 
frequency  in  the  sexes,  different  statements  will  be  found  in  the  works  of 
different  writers,  according  to  the  experience  each  has  had,  and  consider- 
able reasoning  has  been  indulged  in  to  explain  why  the  disease  should  be 
more  common  in  the  one  sex  than  in  the  other.  In  a  collection  of  one 
hundred  and  seven  cases,  I  have  found  fifty  in  mules  and  fifty-seven  in 
females. 

The  locality  in  which  the  disease  first  appears  varies.  Quain  '  says  : 
"  I  have  most  frequently  met  with  the  lower  margin  of  the  deposit  at  the 
distance  of  from  two  to  three  inches  above  the  orifice  of  the  bowel.  The 
part  between  tliat  just  indicated  and  the  anus  is  next  in  order  of  fre- 
quency as  the  seat  of  the  disease,  and  to  this  succeeds  the  lower  end  of  the 
colon."  This  perhaps  expresses  the  facts  of  the  case  as  well  as  they  could 
be  stated  in  a  few  words.  The  upper  limit  of  the  rectum,  where  it  joins 
the  sigmoid  flexure,  is  a  common  site  of  the  disease,  and  here  it  runs  a 
more  rapid  course  then  elsewhere,  and  is  more  apt  to  be  suddenly  fatal  on 
account  of  the  increased  liability  to  obstruction  which  the  anatomical  con- 
dition favors. 

The  symptoms  of  cancer  of  the  rectum  may  be  classified  as  follows: 
pain;  those  due  to  contraction,  to  ulceration,  to  invasion  of  neighboring 
parts;  and,  lastly,  the  generalization  of  the  disease  and  the  cachexia. 

A  cancer  of  the  rectum  may,  and  often  does,  begin  so  insidiously  that 
its  existence  is  not  suspected  by  the  patient  till  it  has  made  irreparable 

'  Diseases  of  the  Rectum,  London,  1879,  p.  265. 

*  Injuries  and  Diseases  of  the  Rectum,  London,  1833,  p,  188. 

3  Molliere  :  Traite  des  ]\Ialadies  du  Rectum  et  de  I'Anus,  Paris,  1877,  p.  580. 

*  Proc.  of  the  Path.  Soc.  of  London,  1846-7. 
» Op.  cit. 


CANOEB.  229 

progress.  This  will  be  the  case  particularly  when  the  disease  is  well  up 
in  the  bowel  beyond  the  reach  of  the  sphincters.  The  slight  sensitiveness 
of  the  mucous  membrane  of  the  rectum  proper  which  permits  the  exist- 
ence of  extensive  ulceration,  the  application  of  escharotics,  and  the  per- 
formance of  surgical  operations  without  pain  has  been  already  referred  to. 
On  the  other  hand,  cancer  of  the  rectum  is  usually  attended  with  great 
pain,  and  the  suffering  in  itself  may  be  made  of  great  assistance  in  diag- 
nosis. 

Attention  lias  been  called  to  the  point  in  diagnosis  that  the  existence 
of  pain  or  cramp  in  the  lower  extremity  in  cancer  of  the  rectum  is  a  bad 
sign,  suggesting  a  direct  encroachment  upon  some  of  the  neighboring 
nerves,  either  by  implication  and  pressure  of  the  glands,  or  by  direct  ex- 
tension of  the  original  disease.'  In  the  later  stages  of  cancer  the  pain 
is  often  the  most  important  symptom  to  be  met  by  treatment.  It  may 
then  be  due  to  the  irritation  of  faeces  upon  an  ulcerated  surface,  to  the 
involvement  of  the  anus  in  the  ulceration,  or  to  direct  pressure  on  adja- 
cent parts,  and  each  of  these  is  to  be  met  by  a  different  and  appropriate 
treatment. 

Ti\e  symptoms  directly  referable  to  contraction  of  the  bowel  are  often 
slight,  and  differ  in  no  way  from  those  caused  by  the  simple,  fibrous 
stricture  of  the  same  part.  It  is  often  astonishing  to  the  surgeon  to  meet 
with  an  advanced  case  of  scirrhus  in  which  the  calibre  of  the  bowel  is  so 
nearly  occluded  as  scarcely  to  permit  the  passage  of  the  end  of  the  finger, 
and  yet  in  which  the  patient  has  never  had  sufficient  uneasiness  to  call 
for  a  direct  rectal  examination. 

The  hsemorrhago  from  an  ulcerated  rectum  in  cancerous  disease  is 
seldom  profuse  enough  to  be  dangerous,  through  by  frequent  repetition 
it  may  become  an  important  factor  in  the  ultimately  fatal  result.  The 
odor  of  tlie  discharge  is  the  same  as  that  from  a  cancer  of  the  uterus,  and 
needs  only  once  to  be  appreciated  to  be  remembered. 

Above  the  contraction  there  often  develops  an  ulceration  which  is  not 
to  be  confounded  with  the  breaking  down  of  the  cancer  itself.  When  the 
cancer  itself  once  begins  to  break  down  and  ulcerate,  its  extension  is 
limited  by  no  tissue  of  the  body.  The  bladder  may  be  opened  and  a 
permanent  fistula  result,  in  which  case  the  passage  is  generally  from  that 
viscus  into  the  rectum;  but  the  opposite  may  be  the  case — and  the  pain 
caused  by  the  entrance  of  faeces  into  the  bladder  and  their  discharge 
through  the  urethra  is  one  of  the  best  of  all  the  indications  for  colotomy. 
The  prostate  and  seminal  vesicles  in  the  male  and  the  recto-vaginal  sep- 
tum in  the  female  may  each  be  destroyed;  in  fact,  any  part  near  tlie 
disease  may  be  implicated.     Smith*  has  recorded  a  case  in  which  the 


'  Hilton:  Rest  and  Pain.  p.  163. 
'Surgery  of  the  Rectum.  London.  1871. 


230  DISEASES    OF    THE    BECTUM    AND    ANUS. 

disease  opened  into  the  hip-joint,  and  Molli^re'  another  in  which  it  in- 
vaded the  soft  parts  in  the  loin. 

There  are  two  sets  of  lymphatics  which  may  be  involved  in  malignant 
disease  of  the  rectum,  one  coming  from  tlie  anus  and  going  to  the  glands 
in  the  groin;  and  one  coming  from  the  rectum  proper  and  going  to  the 
glands  in  the  hollow  of  the  sacrum  and  lumbar  region.  The  proper 
place,  therefore,  to  feel  for  glandular  involvement  in  disease  Avithin  tlie 
sphincter  is  along  the  spine,  deep  in  the  pelvis — a  simple  point  which 
may  decide  the  surgeon  for  or  against  operative  interference.  This  im- 
plication of  the  lymphatics  is  sometimes  shown  by  pressure  effects  at 
points  quite  remote  from  the  original  disease,  as  in  the  following  case 
from  my  own  case-book. 

Case  XXIV. — J.  B.,  aged,  sixty,  has  always  been  strong  and  well 
until  within  a  few  weeks  past,  when  he  has  been  troubled  with  obstinatt 
constipation.  All  he  desires  now  is  some  ''pills"  to  move  his  bowels. 
On  closer  questioning,  he  refers  casually  to  the  fact  that  he  has  consider- 
able pain  in  the  right  thigh,  and  some  swelling  in  the  right  leg  and  foot, 
but  "nothing  to  speak  of."  On  examination,  nothing  was  to  be  detected 
by  rectal  touch,  but  the  pelvis  at  its  upper  part  was  j^artially  filled  by 
firm,  nodular  masses,  which  extended  deeply  down  into  the  right  iliac 
fossa.  The  patient  had  no  conception  of  any  trouble  beyond  constipation 
and  "rheumatism,"  though  the  whole  lower  extremity  on  the  right  side 
was  oedematous.  By  careful  diet  and  laxatives  the  threatened  obstruction 
was  avoided,  and  the  man  gradually  sank  with  all  the  signs  of  the  cancer- 
ous cachexia,  and  died  three  months  from  the  first  examination.  Unfor- 
tunately no  autopsy  could  be  obtained. 

From  what  has  been  said,  it  is  evident  that  there  is  little  in  the  his- 
tory which  the  patient  will  give  of  cancer  of  the  rectum  to  distinguish  it 
from  ulceration  and  stricture  of  any  other  variety,  and  that  the  diagnosis 
must  chiefly  rest  upon  a  physical  examination.  To  make  such  an  exami- 
nation thoroughly,  and  yet  safely,  requires  great  care  and  gentleness,  and, 
to  properly  interpret  the  conditions  which  may  be  found,  no  little  experi- 
ence and  knowledge.  It  requires  many  years  of  practice  to  reach  the 
point  Allingham  has  reached  when  he  says:  "  There  is  something  peculiar 
about  the  feel  of  cancer  which  tlie  practised  finger  rarely  mistakes  even 
for  simple  indurated  ulceration.  I  think  it  is  many  years  now  since  I  mis- 
took the  one  for  the  other." 

In  the  majority  of  cases  the  diagnosis  may  be  made  by  the  history  and 
by  physical  examination  Avith  the  finger  alone.  Cancer  in  this  locality 
is  a  disease  of  rapid  growth,  and  when  a  patient  says  that  stricture  has 
existed  any  considerable  number  of  years  the  idea  of  malignancy  may  be 
abandoned.  Something  also  may  be  learned  from  the  general  appearance 
of  the  patient,  but  most  of  all  from  the  digital  examination.     When  the 

'  Op.  cit.,  p.  565. 


CANCER.  231 

disease  is  seen  in  its  earlier  stages,  the  hard,  more  or  less  distinctly  circum- 
scribed new  growth  which  has  infiltrated  the  wall  of  the  bowel  is  diagnos- 
tic. The  great  difficulty  is  to  distinguish  between  an  advanced  case  where 
the  rectum  is  partially  occluded  by  hard  masses  of  disease,  and  an  old  case 
of  stricture  and  ulceration  which  is  not  malignant.  This  may  sometimes 
be  impossible  except  by  the  microscope,  and  syphilitic  disease  of  the  rectum 
is  not  infrequently  mistaken  for  cancer.  When  a  soft  friable  mass  of 
epithelioma  is  found  seated  on  a  hard,  infiltrated  base,  which  is  ulcerated 
in  spots,  the  edges  of  the  ulcers  being  hard  and  raised,  the  diagnosis  is  also 
eas/. 

Cancerous  stricture  of  the  sigmoid  flexure  will  show  itself  sooner  or 
later  either  by  examination  through  the  abdominal  wall,  or  by  the  signs 
of  intestinal  obstruction. 

In  cases  where  the  condition  is  more  complicated  and  where  secondary 
deposits — in  the  liver,  for  example — have  begun  to  do  their  fatal  work 
before  actual  obstruction  has  begun,  these  symptoms  of  stricture  may  all 
be  obscured  by  the  presence  of  others  which  shall  more  readily  attract  the 
eye.  In  a  case  which  I  now  have  under  treatment,  I  had  made  the  diag- 
nosis of  cancer  of  tlie  liver  with  ascites  and  great  intestinal  disturbance 
some  time  before  my  attention  was  called  to  the  rectum,  and  it  become 
evident  by  examination  that  the  affection  of  the  liver  was  secondary  te 
malignant  disease  high  up  in  the  rectum,  which  was  also  gradually  involv- 
ing the  pelvic  viscera.  Tiie  greatest  caution  should  be  exercised  in  the 
examination  for  cancerous  disease  above  the  lower  four  inches  of  the  rectum. 

Treatnient. — The  treatment  of  malignant  disease  of  the  rectum  is  de- 
signed to  be  either  curative  or  palliative.  In  a  small  number  of  selected 
cases  a  cure  is,  perhaps,  possible,  as  with  cancer  of  feeble  malignancy  in 
other  parts  of  the  body — e.  g.y  epithelioma  of  the  lip.  At  all  events,  the 
disease  may  be  removed,  and  its  return  delayed  for  many  years.  This 
fact,  we  believe,  may  be  accepted  as  proved  by  a  sufficient  number  of 
carefully  examined  cases,  from  which  the  chances  of  error  in  diagnosis 
and  subsequent  history  have  been  eliminated.  Cure  can,  however,  only  be 
effected  by  excision.    All  other  means  may  be  set  aside  as  hopeless  failures. 

The  operation  of  excision,  which,  after  being  fully  described  and  ably 
advocated  by  Lisfranc  in  1830,  was  allowed  to  fall  into  disuse,  has  again, 
within  the  past  few  years,  become  popular.  It  would  probably  be  a  waste 
of  time  to  inquire  to  whom  the  credit  of  reviving  it  is  due.  Cases  of  its 
occasional  performance  are  scattered  through  the  surgical  literature  of  the 
rectum  from  the  early  part  of  the  century  to  the  present,  and  just  now  it 
is  at  the  height  of  its  popularity.  Like  every  other  surgical  procedure  at 
that  point  of  its  history,  it  is  perhaps  also  occasionally  done  when  it  were 
better  to  be  content  with  less  radical  measures.  As  a  result  of  a  careful 
search  among  the  statistics  of  this  operation,  Cripps  '  gives  the  following 

'  Op.  cit.,  p.  166. 


232  DISEASES    OF   THE    BECTUM    AND    ANCS. 

figures.  Out  of  a  total  of  sixty-four  cases,  eleven  died  as  a  direct  result 
of  the  operation;  six  from  peritonitis,  one  from  cellulitis,  and  four  from 
accidents  incident  upon  any  surgical  interference. 

In  the  fifty-three  cases  of  recovery,  the  subsequent  history  is  unknown 
in  sixteen,  and  in  three  more  the  diagnosis  was  so  doubtful  as  to  exclude 
tliem  from  the  list.  No  case  is  worth  much  in  the  consideration  of  a 
question  such  as  this  where  the  diagnosis  has  not  been  verified  by  the 
microscope  in  competent  hands;  for  there  are  non-malignant  growths  of 
this  part  which,  to  the  naked  eye,  strongly  resemble  cancer.  We  have 
then  a  remainder  of  thirty-four,  in  whom  the  disease  returned  in  twenty; 
but  of  these  twenty,  several  were  operated  on  a  second  time  for  a  re- 
currence of  the  growth,  or  possibly  for  a  small  nodule  which  had  not  been 
removed  at  the  first  operation,  and  after  this  second  operation  remained 
free.  This  leaves,  however,  a  total  of  twenty-three  out  of  sixty-four  ope- 
rations in  which  the  disease  had  not  returned,  after  an  interval  varying 
from  a  few  months  to  over  four  years — a  limit  reached  in  three  cases.- 

This  is  certainly  an  encouraging  result  for  this  disease,  and  the  fact 
that  undoubted  cancer  may  be  removed  and  not  reappear  for  such  a 
length  of  time  is  decisive.  Some  operators,  however,  report  better  re- 
sults than  these,  and  some  have  not  been  so  successful.  Curling '  gives 
one  case  of  removal  of  an  epithelioma  in  which  there  had  been  no  return 
in  the  rectum  after  seven  years,  though  for  one  year  there  had  been  "a. 
doubtful  tumor  of  the  pelvis."  Yelpeau  and  Verneuil  each  report  cases 
in  which  the  cure  has  seemed  permanent,  and  Chassaignac  gives  several 
in  which  there  bad  been  no  return  after  six  years.  Dieffenbach's  thirty 
cases  in  which  the  patients  lived  many  years  without  a  return  are  gener- 
ally looked  upon  with  suspicion.  Allingham,*  on  the  contrary,  considers 
the  partial  removal  of  the  circumference  of  the  bowel  as  unsatisfactory. 
In  all  of  his  thirteen  cases  in  which  he  was  able  to  follow  the  progress  of 
the  case  for  one  year,  there  was  either  a  return  of  the  groAvth  in  the  rec- 
tum or  the  glands  in  the  groin  became  affected,  and  there  ensued  disease 
in  the  internal  organs.  In  four  cases  the  disease  did  not  return  in  the 
bowel,  but  in  the  inguinal  glands,  proving  that  it  was  not  due  to  an  in- 
complete operation.  With  regard  also  to  his  ten  cases  of  total  extirpa- 
tion, he  speaks  very  cautiously.  He  believes  that  a  cure  is  very  uncom- 
mon, and  not  generally  to  be  expected;  and  he  does  not  commit  himself 
even  on  the  question  of  the  prolongation  of  life.  The  mortality,  as  a 
direct  result  of  the  operation,  is  generally  about  twenty-five  per  cent. ' 

Billroth  *  reports  thirty-three  cases.  Thirteen  died  of  the  operation, 
and  the  remainder  all  died  within  two  years,  most  of  them  of  recurrence. 

'  Diseases  of  the  Rectum,  ed.  of  1876,  p.  164. 
«  Loc.  cit.,  p.  277. 

2  MoUiere,  Traite  des  Maladies  du  Rectum  et  de  I'Anus,  Paris,  1877,  p.  627. 
*  Clinical  Surgery.     Extracts  from  the  Reports  of  Surgical  Practice  Between 
the  Years  1860-1876.     By  Th.  Billroth.  New  Sydenham  Society,  1881. 


CANOEB.  233 

The  deaths  immediately  following  the  operation  were  invariably  due 
to  retro-peritoneal  sui)piiration,  characterized  by  acutely  septic  symp- 
toms.    Most  of  them  died  within  from  four  to  eight  days. 

Since  then,  in  certain  cases,  we  are  justified  in  expecting  recovery 
from  the  operation  itself,  and  such  a  length  of  life  as  would  not  result 
were  the  disease  left  to  its  natural  course,  we  may  ask  :  1.  "What  are  the 
dangers,  and  what  is  the  mortality  of  the  operation?  2.  In  what  class  of 
cases  is  it  applicable?  3.  What  are  its  results  as  a  curative  and  as  a  pal- 
liative measure,  and  how  do  these  results  compare  with  those  of  lumbar 
colotomy?  4.  What  are  the  results  as  regards  the  subsequent  condition 
of  the  bowel,  and  the  control  of  the  faecal  evacuations?  5.  What  is  the 
best  method  of  its  performance? 

For  the  purpose  of  arriving  at  a  knowledge  of  what  experience  has 
already  taught  in  this  matter,  I  collected,  a  couple  of  years  ago,"  the  re- 

*  For  the  full  literature  of  the  cases  upon  which  these  conclusions  are  based, 
the  reader  is  referred  to  the  following  bibliography: 
Agnew.— Phil.  Med.  Times,  June  23d,  1877. 
AUingham. — Diseases  of  the  Rectum,  3d  ed.,  London,  1879. 
Briddon. — Med.  Record,  January  6th,  1877. 

Bushe. — Treatise  on  Diseases  of  the  Rectum,  New  York,  1837,  p.  294. 
Byrne. — Annals  of  the  Anat.  and  Surg.  Soc.,  May,  1880. 
Baumes.— Bull,  de  TAcad.  Roy.  de  Med.,  t.  x.,  p.  938. 
Cha.ssaignac. — Traite  de  Tecrasement  lineaire,  Paris,  1856. 
Cripps. — Cancer  of  the  Rectum. 
Crosse  (quoted  by  Mayo). — Observations  on  Diseases  and  Injuries  of  the  Rec. 

turn,  London,  1833,  p.  210. 
Curling. — Observations  on  Diseases   of  the  Rectum,    London,    1851.     Med. 

Times  and  Gaz.,  March  Uth,  1857. 
Dennonvilliers. — Gaz.  des  Hop.,  1844. 
Desgranges  (quoted  by  Molliitre).— Maladies  du  Rectum,  etc.,  Paris,  1877,  p. 

627. 
Dieffenbach. — Die  operative  Chirurgie,  Leipzig,  1845. 
Dolbeau. — Thtjse  de  Fumouze. 
Duplay.— Gaz.  Med.  de  Paris,  1872,  p.  486. 

Dupuy.— Bull,  de  la  Soc.  Anat.,  Paris,  1872.     2-  s.,  xvii.,  p.  242. 
Emmet. — Principles  and  Practice  of  Gynaecology,  1st  ed.,  Philadelphia,  1879, 

p.  511. 
E wart.— Lancet,  June  21gt,  1879. 
Fenwick. — Montreal  Gen.  Hosp.  Reports,  vol.  i. 
Gay.— Lancet,  June  28th,  1879. 
Gosselin.— Gaz.  des  Hop.,  1879,  p.  921. 

Holmer.— Hospitals-Tidende,  March  3l8t,  April  7th,  14th,  1880. 
Holmes. — Trans,  of  the  Clin.  Soc.  of  London,  1878,  p.  118. 
Holt  (quoted  by  Curling),  op.  cit.  I 

Keyes. — Arch,  of  Med.,  August,  1879. 
King.— Brit.  Med.  Jour.,  June  2l3t,  1879. 
Kumar.- Wiener  med.  Woch.,  1878,  p.  1,070. 
Labbe.— Gaz.  des  Hop..  June  4th,  18th,  1880. 
Levis— Arch,  of  Clin.  Surg.,  Februarj-,  1877. 


234  DISEA.SES    OF    THE    KECTDM    AND    ANUS. 

ports  of  operations  up  to  that  time  as  far  as  they  were  then  attainable. 
The  list  at  that  time  included  one  hundred  and  forty  cases.  At  that 
time  I  arrived  at  the  following  general  conclusions  concerning  tiie  opera- 
tion, and  subsequent  study  of  the  question  has  led  me  in  no  way  to  alter 
them. 

1.  Although  there  have  been  a  few  cases  of  excision  in  which  the  cancer 
has  not  returned  in  a  nuniber  of  years,  such  a  result  is  so  rare  as  not  to 
justify  the  exposure  of  the  patient  to  the  risk  of  immediate  death  tohich 
attends  the  attempt  to  remove  extensive  disease. 

Regarding  the  question  of  radical  cure,  we  find  difficulty  in  establish- 
ing exact  dates,  and  have  to  take  into  consideration  the  reputation  of  the 
reporter.  We  find,  however,  that  in  one  hundred  cases  (deducting  those 
immediately  fatal,  and  seventeen  which  passed  out  of  observation  imme- 
diately after  operation)  we  have  five  cases  of  reported  permanent  cure,  in 
which  there  had  been  no  return  for  at  least  ten  years.  Three  of  these 
are  reported  by  Volkmann,  and  two  by  Velpeau.  March,  of  Albany,  has 
been  credited  with  another  case  of  radical  cure,  but  the  author  is  much 
indebted  'to  the  present  Dr.  March  for  a  letter  stating  that  the  case  of 

Lisfranc. — These  de  Pinault,  1829. 

Maisonneuve. — Union  Med  ,  1865.     Also  These  de  Cortes,  1860. 

Mandt— Revue  Med.,  1836,  p.  264. 

March.— Trans,  of  the  N.  Y.  State  Med.  Soc,  1868;  also  Med.  and  Surg.  Re- 
porter, June  9th,  1877. 

Mayo. — Observations  on  Diseases  and  Injuries  of  the  Rectum,  London,  1833, 
p.  212. 

Moore. — Med.  Times  and  Gaz.,  March,  1857. 

Molliere. — These  de  Carcopino,  1879. 

Nussbaum. — Aerztlich.  Intelligenzblatt,  1863. 

O'Hara. — Phila.  Med.  Times,  vol.  viii. 

Paget  (quoted  by  Cripps),  op.  cit. 

Peters.— Arch  of  Med.,  August,  1879. 

Pital  du  Cateau. — L'Experience,  t.  vi.,  p.  27. 

Polaillon.— Gaz.  des  Hop.,  1879. 

Post.— Med.  Record,  July  31st,  1880. 

Recamier. — ^These  de  Masse,  1842. 

Roddick. — Montreal  Gen.  Hosp.  Reports,  vol.  i. 

Schuh. — Abhandlung  der  Chir.  und  Operationslehre,  Wien,  1867. 

Siebold  (quoted  by  Curling),  op.  cit. 

Simon.— Lancet,  1851,  ii.,  1882. 

Simon,  of  Rostock. — Deutsche  Klinik,  1866. 

Stimson. — Arch,  of  Med.,  August,  1879. 

Terrillon.— These  de  Carcopino,  1879. 

Van  Buren. — Arch,  of  Med.,  August,  1879. 

Van  Derveer. — Med.  Record,  September  20th,  1879. 

Velpeau. — Nouveaux  Elemens  de  Med.  Operatoire,  Paris,  1839,  vol.  iv.,  p.  814. 

Verneuil  (quoted  by  Marchand). — Etude  sur  I'Extirpation  de  I'Extremite  In- 
ferieure  du  Rectum. 

Volkmann.— Klin.  Vortrage,  March  13th,  1880. 


CAKCEB.  235 

supposed  radical  cure  reported  by  his  father  passed  out  of  observation  at 
the  end  of  one  year.  There  are  some  other  cases  which  have  been  in- 
cluded in  the  category  of  permanent  cures — cases  in  which  the  disease 
had  not  returned  in  four  or  five  years — but  the  great  majority  recur 
within  the  first  year  and  are  fatal  within  two. 

2.  The  operation  is  chiefly  valuable  as  a  palliative  measure  and  as  such 
it  compares  favorably  with  colotomy  both  in  prolonging  life  and  relieving 
pain. 

The  treatment  of  cancer  of  the  rectum  by  excision  has  not  yet  been 
accepted  by  the  surgical  world  as  a  substitute  for  other  measures  even  in 
cases  best  adapted  for  the  operation,  although  it  cannot  be  denied  that  a 
radical  cure  has  sometimes  been  obtained,  and  that  in  many  other  cases 
life  hiis  been  prolonged  beyond  what  could  have  been  hoped  for  by  any 
other  means  of  treatment.  It  is  no  less  true  that  the  operation  is  one  of 
great  danger,  and  that  there  are  not  lacking  those  whose  experience  has 
led  them  to  believe  that  life  was  rather  shortened  than  lengthened  by  it. 
By  these  it  is  claimed  that  in  lumbar  colotomy  we  have  a  safer  method  of 
relieving  pain,  and  delaying  the  progress  of  the  growth,  and  in  both 
these  ways  prolonging  life.  American  and  British  surgeons  hold  rather 
to  this  latter  idea,  while  the  French  and  the  Germans  favor  excision. 

Excision  can  scarcely  be  judged  in  comparison  with  colotomy,  being 
applicable  properly  only  to  an  entirely  different  class  of  cases.  In  cancer 
above  four  inches  from  the  anus,  colotomy  or  colectotomy  are  about  the 
only  means  of  relief.  In  cancer  within  four  inches  of  the  anus  almost 
any  other  plan  of  treatment  is  preferable. 

This  leads  me  to  call  attention  to  another  point — the  operation  of 
excision  as  a  palliative  measure.  In  cases  properly  chosen,  where  the 
disease  is  not  so  extensive  as  to  render  its  removal  one  of  the  capital  sur- 
gical operations,  we  know  of  nothing  better,  and  this  fact  cannot  fail  to 
be  deeply  impressed  upon  the  reader  of  these  cases.  Tiie  statement  that 
all  suffering  was  relieved  is  almost  invariable.  In  almost  every  case  at- 
tention is  called  to  the  great  improvement  in  general  health,  the  loss  of 
pain,  and  the  increase  in  strength.  Patients  go  away  believing  them- 
selves radically  cured,  return  to  their  employments,  and  are  reported  by 
the  French  surgeons  as  '* parfaitement  gueries,"  a  few  weeks  after  the 
operation. 

It  has  been  claimed'  against  this  operation  that  even  when  a  good 
immediate  result  is  obtained,  it  may  shorten  life  by  hastening  the  return 
and  final  progress  of  the  disease.  Unfortunately,  it  is  difficult  to  tell  in 
any  particular  case  how  long  a  patient  would  have  lived  had  tiie  disease 
been  left  to  its  course;  but,  accepting  as  a  basis  for  comparison  Ailing- 
ham's  estimate  of  the  average  duration  of  life  in  cancer  of  the  rectum  as 
two  year^  or  less,  we  are  justified  in  concluding  that  in  all  cases  where 

>  LnbbfS  Gaz,  Hebdom.,  June  4th,  18th,  1880. 


236  DISEASES    OF   THE   RECTUM    AND    ANUS. 

life  was  prolonged  more  than  one  year  and  a  half  after  the  time  of  opera- 
tion (the  operation  generally  being  done  late  in  the  disease),  this  length 
of  life  may  fairly  be  attributed  to  the  surgical  interference.  This  esti- 
mate is  manifestly  a  small  one,  for  a  study  of  the  cases  makes  it  evident 
that  many  who  did  not  live  eighteen  months  after  the  operation  yet 
gained  a  considerable  length  of  comfortable  existence;  and  there  is  noth- 
ing to  prove  that  in  any  case  the  operation  hastened  the  natural  course 
of  the  disease. 

I  have  carefully  searched  tlie  record  of  cases  in  which  a  return  of  the 
disease  within  six  months  of  the  time  of  operation  is  reported,  to  discover 
whether,  here  also,  there  was  any  marked  relation  between  this  result  and 
the  nature  or  extent  of  the  disease  at  the  time  of  operation;  but  it  is 
especially  at  this  point  that  the  table  fails  us.  A  proper  answer  to  this 
question  involves  not  only  a  careful  report  of  the  extent  of  the  disease, 
but  a  microscopic  study  of  its  character,  and  such  data  are  given  only 
in  a  relatively  small  proportion  of  cases.  I  believe,  however,  that  the 
cases  show  a  marked  relation  between  the  rapidity  of  the  growth  before 
operation  and  the  speedy  return  after  removal. 

We  can  trace  no  connection  between  the  time  of  the  return  and  the 
extent  of  the  disease  removed  when  the  removal  has  been  complete;  and 
the  microscopic  reports  are  too  few  for  general  conclusions  to  be  drawn 
from  them.  I  know  of  no  writers,  except  Stimson  and  Holmer,  who 
have  made  a  careful  study  of  the  specimens  excised,  and  have  given  the 
results;  and,  so  far  as  the  clinical  reports  of  the  German  operators  go, 
they  would  seem  to  give  support  to  their  practice  of  removing  everything 
involved,  no  matter  how  extensive,  in  the  hope  that  the  local  return  may 
be  long  delayed. 

3.  WJie7i  the  disease  reaches  above  three  inches  frorn  the  anus,  or  in- 
volves neighboring  parts  so  as  to  render  its  entire  removal  without  injury 
to  the  peritoneum  questionable,  the  operation  is  coyiira-indicated. 

The  Germans  have  apj)arently  no  limits  to  the  applicability  of  this 
operation.  They  perform  it  in  cases  of  the  most  extensive  disease,  open- 
ing the  peritoneum,  exsecting  the  sacrum  when  necessary  to  reach  its 
upper  limit,  and  removing  the  prostate  and  base  of  the  bladder  when 
they  are  implicated,  balancing  the  risk  of  immediate  death  from  the  op- 
eration against  the  chance  of  radical  cure,  or  prolonged  immunity  from 
return.  Conservative  surgeons  will  hesitate  long  before  accepting  this 
view,  for,  although  very  satisfactory  results  have  been  obtained  in  such 
cases,  they  can  hardly  be  considered  other  than  exceptional,  and  a  study 
of  cases  shows  that  the  frequency  of  the  fatal  result  is  in  direct  propor- 
tion to  the  extent  of  the  operation  attempted.  The  rules  for  the  selec- 
tion of  cases  laid  down  by  Lisfranc  were  these:  when  the  bowel  is  mova- 
ble, in  other  words,  when  the  disease  has  not  involved  surrounding  parts, 
the  operation  should  be  undertaken.  When,  on  the  other  hand,  the  dis- 
ease is  more  extensive,  and  reaches  higher,  he  leaves  the  question  to  be 


OANCEB.  237 

decided  by  future  experience.  I  believe  that  experience  has  now  decided 
against  it.  In  deciding  for  or  against  the  operation,  an  examination  of 
the  glands  in  the  hollow  of  the  sacrum  and  in  the  loins  is  of  great  value, 
for  these  receive  their  lymph  directly  from  the  rectum,  and  may  be  en- 
larged, while  those  in  the  groin,  which  are  supplied  from  the  skin  around 
the  anus,  may  still  be  uninvolved. 

I  siiall  not  stop  at  this  time  to  again  discuss  the  question  as  to  how 
much  of  the  anterior  wall  of  the  rectum  is  uncovered  by  peritoneum,  but 
must  refer  the  reader  to  the  chapter  on  anatomy.  The  height  to  which 
it  is  safe  to  go  cannot  be  definitely  stated  for  all  cases,  the  reflection  of 
the  serous  coat  upon  the  rectum  being  at  a  variable  point.  Fochier'  re- 
ports a  case  in  which  he  used  the  6craseur  at  twelve  centimetres  without 
harm,  and  Allingham,"  who  is  always  a  safe  guide,  has  seen  all  but  the 
lower  two  inches  of  the  bowel  covered  by  peritoneum  in  a  female,  has 
opened  into  it  in  a  male  when  not  moro  than  three  and  one-half  inches 
were  removed,  and  has  taken  away  fully  five  inches  in  a  male  without 
bringing  it  into  view. 

Tliere  is  an  old  rule  for  applying  the  trephine,  that  in  every  instance 
the  operator  should  remember  tluit  some  skulls  are  very  much  thinner 
than  others,  and  he  should  act  on  the  supposition  that  the  particular 
point  upon  which  he  is  operating  is  the  thinnest  part  of  the  thinnest  skull 
ever  seen.  Something  of  the  same  kind  might  be  said  of  the  peritoneum 
over  the  rectum;  and  everybody  who  has  studied  the  anatomy  of  the 
part  knows  how  various  are  the  opinions  of  different  authorities  on  this 
point.  Nevertheless,  a  line  of  danger  can  be  marked  out,  and  that  line 
is  about  three  inches  from  the  anus.  It  is  true  that  more  than  this 
amount  of  the  rectum  has  been  removed  without  encountering  the 
peritoneum,  and  it  has  been  opened  below  this  point;  but  I  should  not, 
for  my  own  part,  hesitate  to  try  to  remove  three  inches  of  the  bowel  for  a 
a  cancer,  and  I  have  refused  to  attempt  to  extirpate  in  an  otherwise  suit- 
able case  because  the  disease  passed  this  line.  The  index  finger  is  a  good 
guide.  What  is  well  within  its  reach  in  a  hand  of  good  length,  it  is  safe 
to  try  to  remove,  provided  it  does  not  involve  surrounding  tissues  to  an 
extent  which  renders  its  complete  removal  impossible.  Whatever  may 
be  said  of  the  impunity  with  which  the  peritoneum  may  be  opened  in 
other  parts  of  the  body  does  not  seem  to  apply  here;  for  I  have  been  able 
to  find  but  three  cases  in  which  that  accident  was  not  followed  by  a  fatal 
result. 

Unfortunately,  the  disease  is  but  rarely  seen  at  a  stage  when  extirpa- 
tion is  justifiable,  that  is  when  it  is  limited  to  a  circumscribed  spot 
within  three  or  three  and  a  half  inches  of  the  anus,  when  it  is  movable 
on  the  muscular  coat,  has  not  invaded  the  deeper  tissues,  and  before 
there  has  been  any  glandular  enlargement. 

•  Lyon  Med.,  February  20th,  1876. 
«  Op.  cit.,  p.  275. 


238  DISEASES   OF   THE   RECTUM    AND    ANUS. 

Although  there  is  a  very  evident  relation,  which  is  shown  by  a  study 
of  the  statistics  of  the  ojieration,  between  the  extent  of  the  operation 
attempted  and  the  favorable  or  unfavorable  results  obtained;  a  fatal 
result  will  often  follow  the  extirpation  of  disease  which  is  comparatively 
slight  in  amount.  The  three  great  dangers  of  the  operation  are  peri- 
tonitis, pelvic  cellulitis,  and  septicaemia.  Hasmorrhage  may  fairly  be 
dropped  out  of  consideration,  for  the  operation  may,  if  desired,  be 
rendered  almost  bloodless  by  the  use  of  the  ecraseur  or  galvano-cautery. 

4.  The  operation  is  not  followed  hy  any  aymoying  after-consequences 
which  are  of  sufficient  gravity  to  contra-indicate  its  performance. 

In  a  small  proportion  of  cases,  there  will  be  complete  incontinence, 
in  a  greater  number  there  will  be  partial  control  over  the  evacuations, 
and  in  a  majority  the  control  will  be  sufficiently  complete  to  prevent  the 
occurrence  of  any  annoying  accident. 

Stricture  to  a  troublesome  extent  is  also  rare,  and  when  it  exists,  it 
may  generally  be  overcome  by  the  introduction  of  bougies.  In  one  case 
reported  by  Verneuil,  a  special  plastic  operation  was  performed  to  relieve 
this  condition,  an  account  of  which  may  be  found  in  the  work  of 
Marchand. ' 

Regarding  the  best  way  of  performing  the  operation,  the  surgeon  has 
his  choice  of  several.  The  first  case  of  extirpation  of  the  rectum  of 
which  we  have  any  record  was  by  Faget,  in  1739,  and  was  not  for  cancer, 
but  simply  a  removal  of  the  lower  portion  of  the  bowel,  which  had  been 
completely  surrounded  and  denuded  by  an  abscess  beginning  in  one 
ischio-rectal  fossa,  and  subsequently  extending  into  the  other.  From 
that  time  until  1826,  the  operation,  as  a  means  of  treatment  of  cancer, 
will  occasionally  be  found  mentioned  in  surgical  literature;  generally, 
however,  only  in  condemnation.  In  1826,  Lisfranc  performed  the  first 
successful  operation  for  cancer;  and  three  years  later,  his  student, 
Pinault,  in  a  these  reported  nine  cases,  and  gave  to  the  procedure  a 
permanent  place  in  literature  and  practice.  In  1833,  Lisfranc  himself 
embodied  the  same  ideas  in  a  paper  read  before  the  Acad.  Royale  de 
Medecine,*  and  from  that  time  the  operation  became  widely  known. 
Since  then,  ife  has  had  its  advocates  and  opponents,  and  has  been  subject 
to  many  modifications  in  its  performance.  For  a  long  time,  it  was  coolly 
received  by  British  surgeons,  but  within  the  past  decade  it  has  received 
a  new  stimulus  from  the  Germans,  and  at  the  time  of  writing,  it  seems 
about  to  be  fairly  tried  by  the  surgical  world,  and  judged  on  its  merits. 

Almost  every  surgeon  \yhose  name  is  prominently  associated  witli  the 
operation  has  had  his  own  favorite  way  of  performing  it;  and  we  shall, 
therefore,  speak  in  detail  only  of  those  which  have  proved  most  acceptable, 

'  Etude  sur  Textirpation  de  I'extremite  inferieur  du  rectum.  Marchand, 
Paris,  1873. 

«Mem.  de  TAcad,  Roy.  de  Med.,  1833,  iii.,  p.  296, 


CANCER.  239 

and  first  of  those  described  by  Volkmann  in  his  Klinische  Vortrdge  for 
March  13th,  1880.  lie  describes  three  different  operations,  depending 
on  the  location  of  the  disease.  The  first  is  for  the  removal  of  a  circum- 
scribed spot  only.  This  is  accomplished  by  dilating  the  anus,  dragging 
down  the  disease,  and  excising  it  in  such  a  way  that  the  wound  shall  not 
cause  subsequent  stricture.  When  the  growth  involves  the  anus,  the 
edges  of  the  wound  are  carefully  brought  together,  stitched  with  catgut, 
and  a  drainage-tube  inserted  between  them.  When  the  growth  is 
entirely  within  the  sphincter,  the  edges  are  brought  together  with  equal 
care,  but  the  tube  is  inserted  through  a  track  made  for  it,  which  com- 
municates with  the  wound  above,  and  perforates  the  healthy  skin  at  a 
point  outside  of  the  border  of  the  sphincter.  When  dilatation  does  not 
suflHce,  the  anus  is  freely  divided  down  to  the  coccyx,  and  this  wound  is 
subsequently  carefully  closed  under  the  antiseptic  precautions. 

In  the  second  class  of  cases  where  the  growth  involves  the  whole  circum- 
ference of  the  bowel,  but  not  the  anus,  tlie  latter  is  divided  forward  into 
the  perineum,  and  backward  to  the  tip  of  the  coccyx,  when  necessary,  to 
give  room  for  manipulation.  The  latter  of  these  two  incisions  is  carried 
as  far  into  the  bowel  as  the  lower  border  of  the  disease,  which  is  then 
removed.  The  mucous  membrane  above  is  stitched  to  that  below,  the  pre- 
liminary incisions  carefully  closed,  and  a  drainage-tube  left  in  the  posterior 
one. 

In  the  third  class,  where  the  disease  involves  all,  or  nearly  all,  of  the 
anus  and  of  the  circumference  of  the  rectum,  the  entire  tube  is  separated 
and  removed  in  a  cylinder.  The  same  preliminary  incisions  may  be 
made  as  in  the  second  class,  and  the  anus  is  surrounded  by  a  circular  cut, 
which  runs  outside  the  sphincter.  From  this  as  a  starting  point,  the 
dissection  is  carried  parallel  with  the  bowel  till  the  upper  portion  of  the 
disease  is  passed.  By  the  use  of  knife,  scissors,  and  fingers  the 
bowel  is  completely  freed,  then  drawn  down  to  the  anus,  and  cut  off 
above  the  disease,  the  healthy  upper  end  being  stitched  to  the  margin  of 
the  skin.  In  case  the  peritoneum  is  opened,  the  wound  is  at  once  \ 
stuffed  with  carbolized  sponge,  and  afterward  carefully  closed  with  \ 
catgut.  The  coccyx  and  part  or  nearly  all  of  the  sacrum  are  removed 
when  necessary  to  make  room,  as  a  preliminary  step. 

The  risk  of  haemorrhage  is  one  of  the  great  objections  to  this  opera- 
tion, and  later  on  we  shall  describe  another  procedure,  which  is  pre- 
ferred by  many,  in  which  the  knife  is  supplanted  by  other  and  bloodless 
instruments.  It  is  no  doubt  true  that  the  deep  dorsal  incision  is  tiie 
key  to  the  operation,  and  greatly  facilitates  the  securing  of  bleeding  ves- 
sels; yet  the  haemorrhage  may  be  so  great  as  to  impede  the  operator 
and  endanger  the  life  of  the  patient.  It  will  be  seen  that,  at  every  step 
in  this  operation,  union  by  first  intention  is  aimed  at,  and  Lister's 
methods  are  carefully  followed.  If  the  elements  of  success  in  Lister- 
ism  are,  as  I  believe,  cleanliness  and  drainage,  these  are  certainly  better 


24:0  DISEASES    OF   THE   RECTUM   AND   ANUS. 

met  by  a  deep  posterior  wound,  which  is  left  open  and  syringed  out  fre- 
quently, than  by  carefully  closing  that  safety-valve  with  catgut  sutures 
and  inserting  a  drainage-tube.  It  will  also  be  observed  that  the  bowel  is 
always  brought  down  and  stitched  to  the  free  edge  below.  To  do  this 
much,  dissecting  is  necessary,  and  but  little  permanent  good  is  gained, 
as  the  stitches  soon  tear  out. 

Maisonneuve  described,  in  U  Union  medicale  of  1860,  an  operation 
which  he  named  i\xe  procede  de  la  ligature  extempora^iee,  and  which  dif- 
fers from  the  preceding  in  being  almost  entirely  bloodless,  although  it 
differs  little  from  the  operation  previously  described  by  Chassaignac, 
under  the  name  Vecrasement  lineaire.  In  the  latter,  the  rectum  is  di- 
vided into  two  lateral  halves  by  the  chain  ecraseur,  and  each  half  of  the 
disease  is  then  attacked  in  the  same  way  and  removed.  In  the  opera- 
tion as  done  by  Maisonneuve,  a  strong  cord  is  substituted  for  the  chain, 
and  the  disease  is  removed  in  the  following  manner.  The  skin  and  sub- 
cutaneous tissue  are  divided  by  a  circular  incision  which  completely  sur- 
rounds the  anus.  The  operator  is  provided  with  several  strong  curved 
needles,  each  of  which  is  to  be  threaded  through  the  point  as  often  as 
used,  with  a  strong  silk  ligature  about  a  foot  in  length.  One  of  the 
needles  with  the  ligature  in  its  point  is  then  passed  from  the  external 
incision  into  the  bowel  above  the  growth,  going  wide  of  the  gut  to  clear 
the  tumor.  The  loop  of  string  in  the  eye  of  the  needle  is  seized  within 
the  rectum  and  drawn  out  of  the  anus,  while  the  needle  is  drawn  back 
out  of  its  own  tract.  The  result  of  this  is  a  double  uncut  ligature,  pass- 
ing from  the  point  where  the  needle  entered  the  external  incision,  out- 
side of  the  tumor,  into  the  rectum  above  it,  and  then  out  of  the  anus; 
and  this  manoeuve  is  repeated  eight  or  nine  times  at  points  around  the 
circumference  of  the  anus  equidistant  from  each  other.  A  strong  whip- 
cord or  bow-string  is  the  next  requisite — about  two  yards  long — and  to 
this  all  the  loops  hanging  from  the  anus  are  attached  at  points  nine 
inches  distant  from  each  other.  Each  of  the  original  ligatures  is  then 
withdrawn  by  the  same  course  it  entered,  carrying  a  loop  of  the  whip-cord 
with  it.  When  all  are  drawn  out,  the  rectum  above  the  disease  is  sur- 
rounded by  a  series  of  loops  of  strong  cord,  and  the  ends  of  each  looj) 
hang  out  from  the  original  incision.  The  ends  are  then  attached  to  an 
Ecraseur,  and  each  loop  made  to  cut  its  way  out  in  turn.  After  all 
have  been  cut  out,  the  lower  end  of  the  bowel  and  the  diseased  mass  are 
of  necessity  completely  separated  from  their  attachments. 

The  operation  performed  by  CrippS  is  a  modification  of  the  two  pre- 
ceding ones,  and  would  seem  to  possess  several  advantages  in  facility  of 
performance.  The  preliminary  dorsal  incision  is  made  from  within  out- 
ward, by  passing  a  strong  curved  bistoury  into  the  rectum,  bringing  its 
point  through  the  skin  at  the  tip  of  the  coccyx,  and  cutting  all  the  in- 
tervening tissue.  The  buttock  is  then  drawn  away  from  the  anus  to  put 
the  tissues  on  the  stretch,  and  a  lateral  incision  made  from  the  prelimi- 


CANCKB.  241 

nary 'cut  behind,  around  the  rectum  to  the  median  line  in  front.  The 
site  of  tliis  incision,  whetlier  inside  or  outside  the  anus,  will  depend 
upon  the  location  of  the  disease,  and  whether  or  not  the  anus  is  impli- 
cated. The  cut  itself  should  be  made  boldly,  and  deep  enough  to  reach 
well  into  the  fat  of  the  ischio-rectal  fossa.  The  forefinger  in  this  incision 
will  readily  separate  the  bowel  from  the  surrounding  tissue,  except  at 
the  attachment  of  the  levator  ani  muscle,  which  should  be  divided  with 
the  knife  or  scissors.  A  piece  of  sponge  is  pressed  into  this  cut  to  restrain 
the  bleeding,  while  the  opposite  side  is  treated  in  the  same  way.  The 
anterior  connections  give  more  difficulty,  and  the  dissection  in  the  male 
is  aided  by  having  a  sound  in  the  urethra.  The  knife  and  scissors  replace 
the  finger  in  this  part  of  the  operation.  AVhen  the  dissection  has  been 
carried  to  a  point  above  the  disease,  the  bowel  is  drawn  down  and  held 
while  the  wire  ecraseur  is  passed  over  it,  and  the  section  made  at  the  re- 
quired level.  After  this  there  may  be  free  but  seldom  serious  haemor- 
rhage. The  vessels  divided  in  the  first  steps  of  the  operation  all  come 
from  the  wall  of  the  bowel,  and  if  ligatured  when  first  cut,  are  again 
opened  with  the  ecraseur. 

When  the  disease  is  located  to  one  side  of  the  bowel,  the  operation  is 
modified  accordingly.  The  preliminary  dorsal  cut  is  the  same,  and  the 
lateral  incision  is  made  on  the  affected  side.  At  the  farther  end  of  this 
lateral  incision,  away  from  the  dorsal  one,  a  needle  carrying  a  cord  in 
its  point  is  passed  around  the  disease  and  into  the  rectum  above  it. 
The  loop  of  cord  is  brought  out  of  the  anus,  attached  to  the  chain  of 
the  6craseur,  and  withdrawn  as  it  entered.  The  chain  is  then  made  to 
cut  its  way  out,  and  a  rectangular  piece  of  the  rectum  is  thus  included 
between  two  longitudinal  incisions,  one  posterior  with  the  knife  and  one 
lateral  with  the  chain.  In  this  rectangle  is  the  cancer,  and  it  is  dis- 
sected upward  from  below,  and  separated  above  by  again  using  the 
Ecraseur. 

Instead  of  the  chain  or  wire  Ecraseur,  the  wire  of  the  galvanic  cau- 
tery may  be  used,  heated  to  a  dull  red,  and  not  a  white  heat,  if  the  desire 
is  to  avoid  haemorrhage.  Or  again,  instead  of  the  wire  the  galvanic  cau- 
tery knife  may  be  used,  and  the  operation  performed  with  bloodless  inci- 
sions. This  is  the  operation  favored  by  Verneuil.  The  rectum  is  first 
divided  into  lateral  halves  with  the  ecraseur,  as  in  the  method  of  Chas- 
saignac,  the  cut  dividing  both  the  anterior  and  posterior  walls.  Then 
with  the  galvanic-cautery  blade  tlie  lateral  halves  are  separated  from 
their  attachments  stroke  by  stroke,  until  a  point  is  reached  above  the 
level  of  the  disease.  The  chain  is  again  slipped  over  the  end  of  each, 
and  the  final  section  made. 

An  ingenious  and  simple  method  applicable  to  certain  cases  hjis  been 
recorded  by  Emmet.'     The  growth  in  the  case  in  which  it  was  used  was 

'  Principles  and  Practice  of  Gynsecology,  ed.  1879. 
16 


242  DISEASES    OF    THE    KECTUM    AND    ANUS. 

an  epithelioma  the  size  of  a  hen's  egg,  situated  on  the  posterior  wall  of 
the  rectum  an  inch  above  the  sphincter,  with  considerable  surrounding 
infiltration.  The  sphincter  Avas  stretched,  and  the  mass  seized  with  a 
double  tenaculum,  and  drawn  well  down  by  an  assistant.  "A  steel 
grooved  director,  as  the  most  convenient  instrument  for  the  purpose,  was 
pushed  through  the  skin  in  front  of  the  coccyx  and  just  behind  the  outer 
edge  of  the  sphincter,  into  the  cellular  tissue  of  the  pelvis,  and  then 
made  to  puncture  the  rectum,  in  healthy  tissue,  just  beyond  the  upper 
edge  of  the  tumor.  The  end  was  turned  out  of  the  gut,  and  pushed  far 
enough  forward  to  rest  on  the  perineum  while  the  other  end  was  over  the 
coccyx.  Then  a  second  director  was  pushed  around  from  the  outer  side 
of  the  muscle  on  one  side,  through  the  cellular  tissue  into  the  rectum, 
across  to  the  other  side,  through  the  cellular  tissue  and  skin  again  to  the 
opposite  side  of  the  muscle.  So  that  the  mass,  with  a  portion  of  the 
rectum  above,  was  now  brought  through  the  anus  and  fixed  by  the  two 
directors,  which  had  been  passed  behind  the  mass  at  right  angles  to  each 
other,  with  their  ends  resting  outside  on  the  soft  parts.  The  chain  of  an 
ecraseur  was  placed  behind  these  two  instruments  and  slowly  tightened 
till  the  whole  mass,  as  transfixed,  was  cut  through  along  the  course  of  the 
directors.  By  this  means,  I  removed  the  entire  sphincter  muscle,  about 
three  inches  of  the  posterior  wall  of  the  rectum,  and  about  an  inch  and 
a  half  of  the  rectal  surface  of  the  recto-vaginal  septum.  The  immedi- 
ate result  was  a  most  formidable  opening  in  the  connective  tissue  of 
the  pelvis,  about  three  inches  in  diameter  and  cone-shaped  from  below." 

Dr.  Rouse'  has  recently  called  attention  to  a  simple  method  of 
avoiding  a  wound  of  the  sphincter,  which  is  applicable  to  some  of  the 
slighter  cases.  A  curved  incision  is  made  parallel  with  the  outer  border 
of  the  sphincter,  and  on  a  line  with  its  outer  limit.  By  introducing 
the  finger  through  the  rectum,  the  growth  may  be  everted  through  this 
incision,  and  removed  with  the  part  of  the  rectal  wall  to  which  it  is  ad- 
herent. 

Perhaps  the  best  of  all  the  operations  we  have  spoken  of  is  the  com- 
bination of  the  ecraseur  and  galvano-cautery  knife,  as  used  by  Ver- 
neuil.  But  the  operator  is  at  liberty  to  choose  from  among  them  all 
the  one  he  considers  easiest  of  performance,  and  most  free  from  the  risk 
of  haemorrhage  or  of  wounding  surrounding  parts. 

A  wound  into  the  vagina,  though  always  to  be  avoided  when  possible, 
may  often  be  necessary  in  order  fully  tq  remove  the  disease.  When  the 
fistula  thus  made  is  not  too  extensive,  it  may  be  closed  immediately  after 
the  operation.  If  large,  it  must  be  left.  A  wound  of  the  urethra  in  the 
male,  when  slight,  is  to  be  treated  as  though  the  patient  had  submitted 
to  an  external  urethrotomy,  by  the  frequent  passage  of  the  sound,  to  pre- 
vent contraction.     When  a  large  piece  has  been  taken  from  the  urethral 

'  Lancet,  Oct.  2d,  1880. 


CANCER.  243 

wall,  a  permanent  recto-urethral  fistula  is  the  necessary  result,  and 
the  clanger  of  fatal  inflammatory  action  is  greatly  increased  from  the 
l)re3ence  of  the  urine  in  the  rectal  wound.  As  for  the  cases  reported  by 
Xussbaiim  and  others,  in  which  the  whole  neck  of  the  bladder,  the 
greater  part  of  the  prostate,  and  the  seminal  vesicles  have  been  removed, 
and  the  patients  have  lived  for  years  in  comfort,  they  are  merely  curiosi- 
ties of  literature.  That  such  a  thing  may  happen  has  been  proved,  but 
that  the  operation  sliould  ever  be  undertaken  in  any  case  where  such  a 
result  is  necessary  for  the  entire  removal  of  the  disease,  has  yet  to  be 
proved. 

It  is  with  this  operation  much  the  same  as  with  proctotomy — by  try- 
ing to  save  too  much,  discharge  is  impeded  and  life  may  be  lost.  Cases 
where  the  whole  of  the  sphincter  is  removed,  together  with  the  skin  of 
the  anus,  do  better  than  those  in  which  an  attempt  is  made  to  save  the 
sphincter  and  drain  the  wound  with  drainage-tubes. 

The  operation  of  excision  has,  with  the  recent  advances  in  abdominal 
surgery,  also  been  applied  to  cancer  of  the  sigmoid  flexure  and  descend- 
ing colon.  This  operation  to  which  allusion  has  already  been  made  and 
to  which  Mr.  Marshall'  has  very  properly  applied  the  name  of  "colec- 
tomy" has  now  assumed  a  definite  place  in  surgery  and  marks  another  of 
the  great  advances  of  the  present  century. 

It  dates  from  the  time  of  Reybard  of  Lyons,*  who  in  1833  removed  a 
tumor  the  size  of  an  orange  from  the  sigmoid  flexure  of  a  man  aged 
twenty-eight  years.  In  this  case  the  tumor  could  be  felt  through  the  ab- 
dominal wall  in  the  left  iliac  fossa,  and  the  incision  was  made  parallel 
with  Poupart's  ligament  and  the  crest  of  the  ilium.  The  tumor  was 
drawn  out  through  this  wound  and  excised  with  three  inches  of  the  ad- 
joining intestine.  The  two  ends  of  the  bowel  were  stitched  together  and 
replaced  within  the  abdomen  and  the  abdominal  wound  was  completely 
closed.  There  was  considerable  local  trouble  for  a  few  days,  but  on  the 
thirty-eighth  day  the  wound  had  entirely  healed  and  the  natural  pas- 
sages were  restored.  Death  occurred  ten  months  after  from  recurrence 
of  the  disease.  This  case  was  subject  to  considerable  discussion  in  the 
academy,  but  was  finally  admitted  as  authentic. 

The  operation  thus  inaugurated  in  1833  has  been  modified  in  two 
essential  particulars  by  subsequent  operators,  one  in  the  choice  of  loca- 
tion of  the  incision,  the  other  in  the  subsequent  disposal  of  the  ends  of 
the  divided  intestine.  Since  the  first  case  by  Reybard,  the  operation  has 
been  performed  at  least  seven  times, 

Gussenbauer,  of  Liege,  has  done  it  twice.  The  first  time  in  1877*  was 
upon  a  male  patient  aged  forty-two  years.     The  tumor  which  was  asso- 

'  Clinical  Lecture  on  Colectomy,  Lancet,  May  6th,  13th,  1882. 
'  Bull,  de  I'Acad.  de  Med.,  vol.  ix.,  1843-4. 
'  Arch.  fQrklin.  Chirurg.,  Bd.  xxiii.,  1879. 


24:4  DI8EA.SE8    OB'    THE    BECTUM    AND    ANL'8. 

dated  with  the  usual  symptoms  of  obstructiou  could  be  felt  in  the  leffc 
side,  but  an  attempt  was  made  to  remove  it  through  an  incision  in  the 
median  line  of  the  abdomen.  This  incision  proving  insufficient,  avus  en- 
larged by  cutting  laterally  as  far  as  the  lumbar  fascia.  Another  compli- 
cation arose  from  the  attachment  of  the  growth. to  the  small  intestine 
which  was  opened,  and  fasces  were  allowed  to  escape  into  the  peritoneal 
cavity.  All  the  intestinal  wounds  Avere  closed  with  sutures,  the  bowel 
was  replaced  within  the  abdomen,  and  the  abdominal  incision  sewed  up. 
In  this  case  death  followed  in  fifteen  hours.  Gussenbauer's  second  case 
was  performed  in  1879,'  and  there  had  been  no  return  of  the  disease  two 
years  later. 

Baum  of  Dantzic*  operated  between  these  two  dates  (1878)  upon  a 
male  patient,  aged  thirty-four  years,  in  a  case  of  doubtful  nature.  He 
first  opened  the  small  intestine  to  relieve  the  symptoms  of  obstruction, 
and  seven  days  later  he  discovered  the  seat  of  the  obstruction  in  the  right 
hypochondrium.  A  second  operation  was  then  performed.  The  abdo- 
men was  again  opened,  this  time  by  a  longitudinal  incision  over  the 
tumor,  two  and  a  half  inches  to  the  right  of  the  median  line,  and  this 
incision  was  afterwards  enlarged  by  another  running  toward  the  right. 
The  growth  was  situated  at  the  junction  of  the  transverse  with  the  as- 
cending colon,  and  was  removed  together  witli  a  piece  of  the  mesentery 
which  contained  an  enlarged  gland.  The  divided  ends  of  the  bowel  were 
invaginated  and  united,  the  intestine  replaced,  and  the  abdominal  wound 
closed.  There  was  considerable  discharge  of  faeces  from  this  opening, 
however,  up  to  the  time  of  death  on  the  ninth  day. 

The  next  case  was  by  Martini,  of  Hamburg/  in  1879,  and  Avas  per- 
formed Avith  the  deliberation  and  consequent  success  Avhich  arise  from  a 
certainty  in  diagnosis  of  the  character  and  location  of  the  tumor.  The 
growth  was  situated  in  the  sigmoid  flexure  and  could  be  felt  both  through 
the  abdominal  wall  and  the  rectum.  The  incision  was  made  o\'er  the 
tumor,  the  intestine  below  was  cut  betAveen  double  ligatures,  the  meso- 
colon was  divided  and  the  affected  glands  excised,  and  finally  four  inches 
of  the  bowel  Avere  excised  together  Avith  the  diseased  mass  and  two  inches 
breadth  of  mesocolon.  After  the  removal  of  such  a  section  it  Avas  impos- 
sible to  approximate  the  divided  ends  of  intestine.  The  rectal  end  was, 
therefore,  invaginated  upon  itself,  closed  with  sutures  and  allowed  to 
drop  into  the  pelvis.  The  upper  extremity  Avas  attached  to  the  incision 
in  the  abdomen  to  form  an  artificial  anus.  There  Avere  no  bad  symptoms 
and  in  a  fcAV  weeks  the  man  was  able  to'return  to  his  business. 

Czerny,  of  Heidelberg,  reported  the  next  successful  case  in  1880,*  in  a 


'  Ztschr.  ftir  Heilk.,  Prag,  1880. 
«  Centralblatt  fur  Chir.,  1879,  Bd.  ii,,  p.  169. 
3  Vierteljahrschrift  fur  Heilk.,  Bd.  i.,  1880. 
*  BerUner  kUn.  Woch.,  1880,  No.  45. 


CANCER.  245 

female  patient,  aged  forty-seven  years.  In  this  case  also  the  growth 
could  l>e  felt  through  the  abdominal  wall  on  the  left  side  and  the  diag- 
Tiosis  was  therefore  positive.  After  opening  thp  abdomen  over  the  tumor, 
the  bowel  was  found  to  be  implicated  at  two  points,  one  at  the  transverse 
colon,  and  the  other  at  the  sigmoid  flexure  which  curved  upward  to  an 
abnormal  degree  and  was  involved  in  the  same  disease  through  a  fold  of 
the  great  omentum.  Two  and  three-quarters  inches  of  the  sigmoid 
flexure,  and  four  inches  and  a  half  of  the  transverse  colon  were  excised 
and  the  cut  ends  of  each  portion  were  united.  The  peritoneum  was 
washed  out,  a  drainage  tube  inserted,  the  abdominal  incision  closed  ex- 
cept for  the  drainage  tube,  and  the  whole  dressed  antiseptically.  For  a 
time  there  w.is  a  discharge  of  faeces  through  the  abdominal  wound,  but 
this  finally  closed  and  the  patient  was  well  in  four  months.  The  return 
of  the  disease  was,  however,  very  rapid,  and  death  was  caused  by  it  in 
about  seven  months  after  the  operation. 

Billroth  operated  next  in  order,  in  1881,'  on  a  male  patient  twenty- 
eight  years  of  age.  The  operation  was  done  antiseptically,  and  the  inci- 
sion was  the  usual  one  for  left  inguinal  colotomy.  The  tumor  involved 
the  lower  half  of  the  sigmoid  flexure,  and  there  was  considerable  involve- 
ment of  the  adjacent  mesentery  and  of  the  tissue  behind  the  bowel.  The 
upper  section  of  the  bowel  was  used  for  the  formation  of  an  artificial 
unus.  The  patient  died  in  about  thirty-six  hours  from  incipient  diffuse 
})eritonitis. 

Bryant's  case  *  is  next  in  order,  and  is  peculiar  in  the  fact  that  the  in- 
cision was  the  usual  one  for  left  lumbar  colotomy.  This,  in  fact,  was  the 
ojKjration  attempted,  but  after  the  bowel  had  been  opened,  the  obstruc- 
tion was  found  to  be  above  the  opening  made.  It  was  then  determined 
10  excise  the  disease,  and  this  was  successfully  done  through  the  original 
incision.  The  two  ends  of  the  bowel  were  attached  to  the  wound,  the 
upper  in  the  usual  manner  for  forming  an  artificial  anus.  The  patient 
recovered,  and  was  well  at  the  time  of  the  publication  of  the  case.  The 
<lisease  constituted  a  cylindrical  stricture  of  limited  extent. 

Finally,  Mr.  Marshall's'  case  has  just  been  published  at  the  time  of 
writing.  The  patient  was  a  woman,  aged  forty-nine  years,  and  no  posi- 
tive diagnosis  as  to  the  seat  of  the  obstruction  could  be  made.  The  diffi- 
culties attending  the  diagnosis  may  best  be  gathered  from  his  own  descrip- 
tion. 

"The  wasting  and  rapid  ageing  of  the  patient,  although  she  took  food 
tolerably  well,  suggested  the  presence  of  a  malignant  stricture,  probably 
opitheliomatous;  but  it  was  difficult  to  say  how  far  the  symptoms  were 
referable  merely  to  the  pain  and  vomiting  which  she  had  suffered;  but, 

>  Wien.  Med.  Woch.,  March  5th,  1881. 

'Lancet,  Vol.  i.,  1882. 

'  Lancet.  May  Cth,  13th.  1882. 


246  DISEASES    OF    THE    KECTUM     AND    ANUS. 

whatever  the  nature  of  the  obstruction,  its  seat  was  obscure.  The  chro- 
nicity  of  the  case  pointed  strongly  to  the  large  intestine,  but  the  abdomen 
was  not  broad  in  shape;  no  tumor  or  scybala  could  be  felt  in  either  iliac 
fossa,  or  elsewhere  along  the  course  of  the  large  gut,  though  both  fossa& 
could  be  well  examined  under  chloroform.  There  was  no  dulness  in 
either  loin  to  indicate  a  full  colon,  and  no  "colonic"  note  to  show  that 
the  bowel  contained  gas.  Rectal  examination  revealed  nothing.  The 
long  tube  passed  one  foot,  and  an  enema  of  three  pints  was  easily  given, 
and  seemed,  from  an  accompanying  diminution  of  resonance  in  the  left 
flank,  to  have  entered  the  descending  colon.  But  as  the  patient  was  lying 
on  the  left  side,  it  was  possible  that  fluid  contents  had  gravitated  into 
the  small  intestines  lying  over  the  descending  colon — a  source  of  movable 
dulness  which,  as  remarked  by  Mr.  Boyd,  is  often  overlooked.  The 
amount  and  uniformity  of  the  abdominal  distention  were  sufficient  to 
prove  that  the  obstruction,  if  in  the  small  intestine,  was  near  the  lower 
end.  If,  however,  the  suspicion  were  correct  that  the  cause  of  the  ob- 
struction was  an  epithelioma,  the  probability  of  its  seat  being  in  the  large 
intestine,  somewhere  beyond  the  caecum,  was  greatly  increased." 

On  account  of  the  uncertainty  in  diagnosis,  the  incision  in  this  case 
was  an  exploratory  one  in  the  median  line,  and  the  growth  was  found  in 
the  descending  colon,  between  the  lower  end  of  the  kidney  and  the  iliac 
crest.  As  it  was  impossible  to  bring  this  part  of  the  bowel  to  the  median 
line,  the  first  incision  was  abandoned,  and  a  second  one  made  over  t}\e 
tumor,  parallel  with  the  last  rib,  and  one  inch  and  a  half  above  the  poste- 
rior part  of  the  iliac  crest.  The  growth  was  cut  out  with  the  scissors, 
together  with  an  inch  of  the  bowel  above  and  below,  between  double  lig- 
atures. The  open  end  of  the  upper  section  of  the  bowel  was  attached  to 
the  abdominal  wound  to  form  an  artificial  anus,  and  the  lower  end  was 
left  projecting  from  the  lower  and  hinder  part  of  the  wound  Avith  the 
strong  catgut  ligature  drawn  tight  upon  it.  The  patient  died  of  perito- 
nitis on  the  third  day. 

Of  these  eight  cases,  one-half  may  fairly  be  said  to  have  prolonged  life, 
and  the  others  have  been  fatal  within  a  short  time  from  peritonitis.  As 
pointed  out  by  Marshall  in  his  instructive  resume  of  the  operation,  the 
result  undoubtedly  depends  in  a  great  degree  upon  the  certainty  with 
which  the  diagnosis  is  made,  or,  in  other  words,  upon  the  exact  adapta- 
tion of  the  operation  to  the  end  to  be  attained.  In  most  of  the  successful 
cases,  the  diagnosis  as  to  the  seat  of  the  obstruction  was  made  before  the 
operation  was  begun,  and  in  all  of  them  only  a  single  incision  was  neces- 
sary to  reach  the  tumor.  In  three  of  the  four  fatal  cases,  two  incisions 
were  made — one  in  the  median  line,  and,  subsequently,  another  to  reach 
the  disease.  In  this  way  the  severity  of  the  procedure  was  greatly  in- 
creased. 

There  seems  to  be  little  difference  in  the  mortality  whether  the  ends 
of  the  divided  intestine  be  united  and  the  abdominal  wound  closed;  or 


CANCER.  247 

one  end  be  brought  to  tlie  surface  for  the  formation  of  an  artificial  anus. 
The  latter  is  the  simpler  procedure;  the  former,  when  successful,  gives 
the  better  result.  A  great  difference  in  the  size  of  the  two  ends  will  some- 
times render  tiieir  union  difficult;  the  upper  one  being  frequently  hyper- 
trophied  and  dilated,  and  the  lower  contracted. 

The  study  of  these  cases  leads  plainly  to  the  following  conclusions: — 

1.  In  cancer  of  the  descending  colon,  sigmoid  flexure,  and  upper  part 
of  the  rectum,  when  the  disease  is  still  movable,  an  attempt  at  its  re- 
moval through  the  abdominal  wall  is  justifiable. 

2.  In  cases  of  obstruction  where  the  symptoms  point  toward  this  part 
of  the  bowel  as  the  affected  part,  even  when  the  diagnosis  is  not  certain, 
it  may  be  well  to  make  the  exploratory  incision  in  the  left  groin  instead 
of  in  the  median  line,  having  in  mind  the  possible  extirpation  of  the  dis- 
ease and  the  formation  of  an  artificial  anus. 

3.  In  cases  of  intended  colotomy  also,  it  may  be  found  possible,  after 
the  incision  has  been  made,  to  substitute  colectomy,  and  this  constitutes 
another  reason  for  choosing  the  inguinal  to  the  lumbar  incision  in  that 
operation,  though,  as  in  Bryant's  case,  colectomy  may  be  done  through 
the  loin. 

4.  The  operation  of  colectomy  compares  very  favorably  with  colotomy 
in  malignant  disease,  and  while  the  latter  may  be  the  more  suitable  in  an 
advanced  case,  the  former  may  give  better  results  when  the  disease  is  in 
its  incipiency. 

The  palliative  treatment  of  malignant  stricture  of  the  rectum  is  in 
many  points  the  same  as  of  non-malignant.  The  relief  of  pain  is  i)erhaps 
a  more  marked  indication  in  most  cases.  The  pain  depends  on  two 
classes  of  causes — those  which  make  cancer  a  painful  disease  wherever 
met  with  in  the  body,  and  those  which  are  due  solely  to  its  situation  at 
the  outlet  of  the  bowel.  Among  the  first,  we  have  pressure  upon  adja- 
cent parts  and  involvement  of  neighboring  organs  and  nerves;  and  among 
the  second,  the  passage  of  faeces  over  an  ulcerated  surface  and  spasm  of 
the  sphincter  muscle  from  irritation  caused  by  its  direct  implication  in 
the  cancerous  growth,  or  by  the  passage  over  it  of  irritating  sanious  dis- 
charges from  the  sore.  From  this  it  is  easy  to  understand  why  cancer  is 
in  one  person  attended  by  excruciating  suffering,  while  another  may 
hardly  be  conscious  of  its  presence;  and  why  tlie  pain  is  in  some  paroxys- 
mal and  particularly  aggravated  by  a  movement  of  the  bowels,  and  in 
others  dull  and  constant,  radiating  through  tlie  loins  and  down  the 
thighs.  For  the  relief  of  this  symptom  we  have  at  our  command:  a. 
Regulation  of  the  passage,  diet,  and  the  recumbent  jwsture;  b.  Anodynes 
locally  and  by  the  mouth;  c.  Partial  destruction  of  the  growth  by  means 
of  the  curette,  cauterization,  or  partial  extirpation;  d.  Division  of  the 
sphincter;  e.  Lumbar  colotomy. 

The  passages  should  be  kept  soft  but  not  fluid,  as  any  approach  to 
diarrhoea  always  aggravates  the  suffering.     This  may  be  done  partly  by 


248  DISEASES    OF   THE    RECTUM    AND    AISTUS. 

the  clioice  of  food,  which  needs  to  be  regulated  with  groat  care  on 
account  of  the  tendency  to  gastric  disturbance,  more  or  less  of  which  is 
always  present;  and  by  the  administration  of  the  mineral  waters,  which 
are  generally  sufficiently  laxative  for  the  purpose.  Rest  in  the  recum- 
bent posture  is  a  means  of  palliation  of  great  value,  sometimes  giving 
more  relief  than  anodynes.  These  latter  may  be  given  both  by  the 
mouth  and  in  enemata,  and  if  possible  should  be  pushed  to  the  point  of 
relieving  suffering.  This  seems  so  plain  a  duty  which  the  surgeon  owes 
to  his  patient,  that  we  need  not  stop  to  discuss  any  possible  moral  bear- 
ing it  may  have.  If  the  agony  of  this  incurable  malady  could  always  be 
relieved  by  the  administration  of  opium,  the  question  of  operative  inter- 
ference would  arise  much  less  frequently  than  it  now  does.  But,  unfor- 
tunately, the  constant  administration  of  this  or  any  other  narcotic  will 
sometimes  cause  gastric  and  mental  disturbance,  harder  to  bear  than  the 
disease.  By  using  the  finger-nail,  a  curette  similar  to  the  one  used  in 
the  uterus,  or  a  scoop  such  as  is  used  for  submucous  uterine  tumors,  the 
pain  may  in  some  cases  be  greatly  relieved  by  a  removal  of  a  part  of  the 
growth  when  of  the  soft  variety.  The  same  may  be  done  by  the  applica- 
tion of  chemically  destructive  agents  or  the  actual  cautery,  and  even  by 
the  partial  excision  of  the  mass,  merely  as  a  means  of  relief  and  where 
there  is  no  question  of  cure.  I  have  already  called  attention  to  division 
of  the  sphincter  muscle  as  a  palliative  measure  in  the  treatment  of  rectal 
disease,  and  all  that  was  said  regarding  the  treatment  of  benign  stricture 
applies  equally  well  to  cancer. 

The  dernier  ressort  of  surgery  for  the  relief  of  pain  is  lumbar  colot- 
omy.  We  have  already  attempted  to  limit  the  scope  of  this  operation. 
In  any  case  in  which  the  suffering  is  due  to  the  direct  contact  of  faeces 
with  the  diseased  surface,  and  is  not  due  to  a  spasmodic  action  of  the 
sphincter  muscle,  and  cannot  therefore  be  relieved  by  the  permanent 
division  and  paralysis  of  that  muscle,  and  is  not  due  to  the  extension 
into  and  pressure  of  the  disease  upon  neighboring  parts,  the  operation 
may  be  tried.  There  may  be  such  cases,  but  they  are  not  common — not 
nearly  as  common  as  is  lumbar  colotomy  for  cancer.  Let  it  be  remem- 
bered, however,  that  after  colotomy  faeces  will  still  find  their  way  to  the 
tender  point,  and  that  the  amount  of  suffering  from  a  small  mass  of 
faeces  may  be  as  great  as  from  the  entire  quantity. 

With  regard  to  husbanding  the  sufferer's  powers  and  prolonging  life, 
much  may  be  done  by  careful  nursing  and  medication.  Milk  is  by  far 
the  best  diet,  and  cod-liver  oil  in  small  "doses  the  best  medicine  where  it 
can  be  borne,  for  it  has  a  laxative  as  well  as  a  tonic  action.  Cleanliness 
is  best  obtained  by  frequent  washing  out  of  the  rectum  with  disinfecting 
fluids,  as  permanganate  of  potash  and  carbolic  acid. 

The  means  of  overcoming  obstruction  in  malignant  disease  are  also 
much  the  same  as  in  benign  stricture,  and  to  what  has  already  been  said 
on  that  subject  we  must  again  refer  the  reader.     Before  commencing  to 


CANCER.  249 

treat  tlie  obstruction  as  such,  it  is  well  to  remember  that  an  exceedingly 
small  outlet  to  the  alimentary  canal  may,  with  proper  care,  be  made  to 
answer  all  the  calls  of  nature.  We  see  this  constantly  in  cases  of  stric- 
ture both  simple  and  malignant,  where  the  finger  cannot  be  forced  through 
the  obstruction,  and  yet  there  is  no  retention;  and  in  such  cases,  by  the 
judicious  administration  of  laxatives,  life  may  be  made  so  comfortable 
that  the  question  of  surgical  interference  shall  be  postponed  indefinitely. 
When,  howevei",  obstruction  is  actually  threatened,  much  may  be  done 
by  the  medical  means  already  pointed  out. 

When  dilatation  becomes  nocessary,  it  should  be  of  the  gentlest  kind. 
The  cases  of  fatal  accident  from  perforation  of  the  bowel  where  the  coats 
have  been  weakened  by  ulceration  are  already  numerous  enough  to  serve 
as  warnings  for  all  future  time.  The  best  of  all  dilators  in  cancerous 
disease  is  the  finger,  either  that  of  the  patient  or  the  nurse,  passed 
daily;  and  none  of  the  mechanical  means  with  which  we  are  acquainted 
equals  this  for  safety  and  comfort. 

When  the  disease  is  beyond  the  reach  of  the  finger,  a  bougie  must  be 
used,  but  the  dangers  are  greatly  increased,  and  it  may  be  better  at  once 
to  make  an  artificial  anus  than  to  incur  the  risk  of  fatal  accident  which 
the  use  of  a  bougie  high  up  the  bowel  certainly  entails.  The  frequency 
with  which  the  bougie  may  be  used  will  depend  upon  the  result  of  its 
trial.  Should  much  irritation,  tenesmus,  or  haemorrhage  follow  its  em- 
ployment, the  patient  will  soon  refuse  to  submit  to  its  continuance; 
while,  on  the  other  hand,  should  the  result  be  favorable,  it  may  be  em- 
employed  daily.  The  softest  bougie  is  the  best,  and  a  candle  often  an- 
swers admirably. 

If  dilatation  be  found  too  painful  or  ineffectual,  as  it  sometimes  will, 
recourse  may  be  had  to  division  or  partial  destruction  of  the  cancerous 
mass.  A  double  proctotomy  may  be  done  in  case  of  malignant  disease, 
and  the  section  of  the  growth  between  the  two  incisions  be  removed,  in 
this  way  opening  once  more  the  calibre  of  the  bowel  and  overcoming  the 
obstruction.  I  have  performed  tliis  modified  operation  with  great  relief, 
and  I  have  also  found  that,  after  making  a  single  free  division  of  the 
cancerous  mass,  large  pieces  adjacent  to  the  cut  could  be  excised  with 
great  facility  and  without  danger.  The  latter  operation  is  rather  the 
preferable  one. 

Relief  both  to  pain  and  obstruction  may  sometimes  be  gained  in  this 
way  by  a  partial  destruction  and  extirpation  of  a  cancerous  growth, 
wliere  its  entire  removal  is  out  of  the  question,  and  its  local  return  may 
be  expected  with  certainty.  By  such  measures,  the  evacuations  may 
be  made  less  j)ainful,  the  spasmodic  action  of  the  sphincter  and  the  rec- 
tal tenesmus  may  be  allayed,  the  cancerous  look  may  for  a  time  disap- 
pear, and  the  patient  recover  sufficient  strength  to  resume  the  ordinary 
occupations  of  life. 

A  growth  may  be  attacked  in  this  way,  either  with  the  knife,  cautery, 


250.  DISEASES    OF   THE    RECTUM    AND    ANUS. 

finger  or  curette.  Caustic  applications  are  of  no  use,  except  in  cases; 
where  a  fungous  mass  has  protruded  from  the  anus.  This  may,  at 
times,  be  removed  with  great  advantage  to  the  sufferer,  by  the  applica- 
tion of  a  paste  of  arsenite  of  copper,  mixed  with  mucilage.  The  opera- 
tions for  removing  a  part  of  the  growth  with  the  finger,  scoop,  or  curette 
may  give  great  relief  in  the  soft  varieties  of  the  disease.  The  sphincter 
should  first  be  thoroughly  dilated,  the  anus  held  open  with  a  speculum, 
and  as  much  of  the  diseased  tissue  as  possible  torn  and  scraped  away. 
Haemorrhage,  of  course,  is  to  be  expected,  but  this  is  less  where  the 
growth  is  boldly  attacked  in  its  deeper  parts  than  when  the  surgeon  is 
timid  and  attacks  merely  the  superficial  portions;  and  may  be  controlled 
either  by  plugging  the  wound  with  lint  and  styptics,  or  by  the  actual 
cautery.  Allingham  relates  a  case  in  which  he  entirely  enucleated  an 
immense  encephaloid  with  his  hand,  with  the  happiest  results. 

As  a  substitute  for  partial  destruction  of  the  growth  in  this  way,  the 
operation  of  crushing  with  an  instrument  similar  to  the  enterotome  of 
Dupuytren  has  been  proposed.  The  proceeding  is  only  applicable  to  a. 
certain  class  of  cases,  in  which  the  stricture  is  annular  and  not  too  ex- 
tensive to  be  grasped  by  the  instrument,  and  has  no  advantages  over  the 
other  methods. 

There  is  no  obstruction  within  four  inches  of  the  anus  which  may  not. 
be  overcome  by  some  one  or  other  of  these  means.  What,  then,  remains 
for  lumbar  colotomy  ?  Simply  those  above  the  reflection  of  the  perito- 
neum. 

It  will  often  be  difficult  for  the  surgeon  to  decide  for  or  against 
colotomy  in  these  cases.  Two  factors  enter  into  the  question:  1st, 
whether  or  not  the  patient  is  likely  to  survive  the  operation  itself;  and, 
2d,  if  this  is  decided  in  the  affirmative,  whether  sufficient  is  to  be  gained 
to  pay  for  the  risk.  The  general  condition  of  the  patient,  the  extent  of 
disease  as  regards  secondary  deposits,  and  the  amount  of  pain  dne  to  de- 
fecation, all  have  to  be  taken  into  consideration.  The  operation  may  be 
indicated  to  relieve  this  pain  when  there  is  not  much  chance  of  actually 
prolonging  life,  and  it  may  be  indicated  to  prevent  or  overcome  obstruc- 
tion where  there  is  no  great  amount  of  pain.  I  am  inclined,  for  myself, 
to  limit  the  operation  to  those  cases  where  the  pain  of  defecation  is  great, 
and  where  the  disease  is  still  circumscribed,  and  should  not  for  the 
choice  between  death  from  obstruction  and  death  a  few  weeks  later  from 
exhaustion  always  have  recourse  to  this  extreme  measure,  but  should 
rather  trust  to  securing  a  comparatively -easy  passing  away  of  the  patient 
under  tlie  influence  of  opium.  Indeed,  many  patients  will  decide  the 
question  in  this  way  for  themselves  when  it  is  explained  to  them  in  all  its 
bearings. 

It  is  a  curious  fact  that,  by  relieving  tlie  over-distention  of  the 
bowels  by  colotomy,  the  obstruction  also  will  sometimes  cease,  and  pas- 
sages will  again  pursue  their  natural  course.     Such  a  case  is  reported  by 


CANCEK.  251 

Goodhart,  where  three  successive. operations  for  opening  tlie  colon  above 
the  stricture  were  resorted  to  to  relieve  obstruction,  and  after  each  one  tlie 
passages  were  again  restored  to  the  natural  outlet 


\ 


252  DISEASES   OF   THE    KECTDM    AND    ANUS. 


CHAPTER    XII. 

IMPACTED    F^CES   AND    FOREIGST   BODIES. 

Impacted  Faeces. — Intestinal  Concretions. — Diagnosis  and  Treatment  of  Impaction. 
— Foreign  Bodies  SwaIlo4ped. — Results  which  may  Follow  the  Swallowing 
of  a  Foreign  Body. — Ulceration  and  Abscess. — Foreign  Bodies  Introduced 
per  Anum. — Cases. — Prognosis. — Treatment. — Dangers  of  Attempts  at  Re- 
moval.— Laparotomy  for  Removal. — Cases  Successful. 

Impaction  of  Fceces. — The  impaction  of  faeces  may  be  due  to  several 
causes,  but  is  most  generally  a  symptom  either  of  intestinal  atony  in  old 
people  or  of  some  paralytic  afifection  such  as  locomotor  ataxia.  It  not 
infrequently  occurs  in  women  as  a  result  of  the  entire  neglect  of  the 
function  of  defecation  for  which  they,  are  perhaps  unjustly  celebrated; 
and  they  may  follow  a  partial  paralysis  of  the  rectum  from  the  long-con- 
tinued use  of  large  enemata,  or  the  pressure  of  the  foetal  head  in  child- 
birth. They  may  also  be  formed  as  a  consequence  of  a  painful  affection 
such  as  a  fissure  which  renders  each  act  of  defecation  an  agony  to  be 
avoided  by  every  possible  means.  The  disease  is  generally  one  of  old 
people,  of  hysterical  girls,  and  of  careless  women;  but  it  has  been  seen  in 
children,  and  as  a  result  of  improper  diet  may  occasionally  be  encoun- 
tered in  young  and  healthy  men. 

Intestinal  concretions  may  be  composed  entirely  of  hardened  and 
stratified  or  clayey  masses  of  faeces,  or  they  may  contain  within  them  as 
a  nucleus  a  biliary  calculus,  or  indigestible  substances  which  have  been 
hastily  swallowed,  such  as  peach-pits,  cherry  stones,  etc.  Molliere  calls 
attention  to  the  presence  of  magnesia  which  favors  the  aggregation  of 
faecal  matters,  and  which  also  may  act  as  the  nucleus  of  a  scybalus;  and 
the  frequency  of  impaction  during  the  famine  in  Ireland  in  1846,  when 
potatoes,  and  those  of  a  very  poor  quality,  were  the  only  article  of  diet, 
is  a  well  known  historical  fact.'  In  Scotland,  where  oat-meal  is  a 
favorite  article  of  diet,  faecal  accumulations  are  said  to  be  of  frequent 
occurrence.  Certain  other  drugs  besides  magnesia,  such  as  chalk, 
sulphur,  and  powdered  cubebs  have  been  blamed  as  the  cause  of  intestinal 
concretions.  Intestinal  calculi  have  been  seen  which  were  composed  of 
pure  cholesterin  or  of  a  biliary  calculus  coated  with  cholesterin. 


'  For  description  of  these  cases  see  article  by  Dr.  Paphana  in  the  Lancet,  1850. 


/ 


IMPACTED    FJS0E8    AND    F0KEI6N    BODIE8.  253 

The  usual  location  of  a  mass  of  impacted  faeces  is  the  rectal  pouch, 
but  it  may  be  situated  anywhere  between  the  caecum  and  this  point.  The 
symj)toms  to  which  it  gives  rise  are  generally  sufficiently  well  marked  to 
enable  the  practitioner  to  reach  a  correct  diagnosis  if  he  be  on  his  guard. 
The  pains  which  it  causes  will  generally  bo  obscure  and  may  be  located 
anywhere  in  the  abdomen  or  in  the  lower  extremities;  and  the  signs  of 
disturbance  in  digestion  are  not  in  themselves  sufficiently  marked  for 
diagnosis,  but  the  one  symptom  which  is  characteristic  is  diarrhoea. 

Just  as  thfe  practitioner  has  to  learn  that  incontinence  of  urine  may 
be  a  sign  of  a  distended  and  not  an  empty  bladder,  so  he  may  have  to 
learn  by  a  disagreeable  error  in  diagnosis  that  a  diarrhoea  is  sometimes  a 
result  of  an  overfilled  and  obstructed  rectum.  This  diarrhoea  is  peculi- 
arly foetid  in  character,  and  the  matters  discharged  may  be  entirely  free 
from  faeces  and  consist  entirely  of  mucus.  In  some  cases  there  may  be 
an  approach  to  a  daily  natural  evacuation.  The  act  of  defecation  is 
always  attended  by  straining  and  pain  as  the  faecal  ball  is  pressed  down 
against  the  perineum  and  rises  again  when  the  muscular  effort  ceases.  To 
these  symptoms  Allingham  adds  a  peculiar  ringing,  barking  cough, 
morning  vomiting  (particularly  in  women),  and  night-sweats. 

Of  course  errors  in  diagnosis  are  easy  in  such  a  condition  as  this, 
and  a  mtiss  of  faeces  in  the  colon  may  be  mistaken  for  any  and  every  sort 
of  tumor  in  the  pelvis  or  abdomen.  Liver,  spleen,  stomach,  uterus,  and 
ovaries  have  again  and  again  beei.  supposed  diseased  in  these  cases  when 
a  simple  digital  examination  of  ,  'e  rectum,  or  in  women  even  of  the 
vagina,  could  not  fail  to  make  the  diagnosis  clear.  Unfortunately  for  diag- 
nosis, the  general  practitioner  is  not  fond  of  making  rectal  examinations, 
and  these  cases  are  not  infrequently  treated  with,  bismuth  and  opium  as 
a  consequence. 

The  following  instructive  case  was  reported  by  Dr.  Griffith.' 

In  the  autumn  of  1876,  I  was  hurriedly  summoned  to  an  old  lady, 
who  had  within  a  few  days  of  my  seeing  her  met  with  a  severe  accident 
in  the  city,  having  been  knocked  down  by  a  hansom  as  she  was  crossing 
the  street.  All  her  friends  had  given  her  up  to  die.  She  was  so  power- 
less to  move,  so  prostrated,  and  so  large  a  tumor,  they  stated  to  me,  had 
made  its  appearance  since  her  injuries.  Her  age  (80)  seemed  to  exclude 
all  hope  of  recovery;  and  I  was  asked  to  see  her — more  that  it  should  not 
be  said  she  had  died  incapable  of  making  her  will  and  to  witness  her 
signature  to  it,  than  with  any  idea  that  I  could  benefit  her. 

I  examined  the  abdomen,  and  while  doing  so  learned  from  her  that 
she  thought  she  had  been  larger  on  the  left  side  for  some  time  before  the 
accident.  I  found  considerable  enlargement  of  the  entire  abdomen  from 
flatulent  distention,  and  on  the  right  side  a  tumor,  hard  and  apparently 

'  Faecal  Accumulations  Stimulating  Utero-Ovarian  Tumors,  Ekiinburgh  Med- 
icalJournal.  Mav.  1S77. 


254  DISEASES    OF    THE    RECTUM    AND    AXUS. 

irregular,  extending  from  the  left  hypochondriac  into  the  left  iliac  fossa 
and  passing  a  little  way  to  tlie  right  of  the  median  line.  At  first,  I 
thought  it  might  be  enlarged  spleen,  or  a  left  ovarian  dropsy,  or  an 
extrauterine  fibroid,  which  had  been  unnoticed,  and  was  now  observed, 
solely  because  attention  was  directed  to  the  left  side,  where  the  patient 
had  been  struck  by  the  vehicle.  I  could  not  at  this,  my  first  visit,  make 
a  very  minute  examination,  owing  to  the  extreme  prostration  and  de- 
pression; but  at  my  second  visit,  having  in  the  interval  built  her  up  and 
cheered  her  all  I  could,  I  examined  very  carefully  per  vaginam,  and  with 
equal  care  explored  by  the  rectum.  I  then  came  to  the  conclusion  that 
there  was  neither  ovarian  nor  uterine  tumors,  and  that  I  had  to  deal  with 
an  accumulation  of  faeces — even  though  the  bowels  were  moved  every  day, 
as  the  attendant  informed  me,  and  that  the  accumulation  had  com- 
menced previous  to  her  accident;  forming,  no  doubt,  the  enlargement 
which  she  told  me  she  had  noticed  before  her  injury,  and  Avhich,  as  the 
accumulation  increased,  culminated  in  the  enlargement  I  found.  I 
swept  out  the  bowels  by  free  purgation,  kept  up  for  some  days,  while  I 
sustained  her  with  light  and  easily  digested  nutrients,  allowing  as  stimu- 
lant only  good  tea  and  coffee. 

The  next  case  is  also  from  the  same  author: 

Mrs.  G.,  aged  twenty-five,  mother  of  three  children;  the  last  being 
about  four  months  old  when  I  was  first  in  attendance.  I  was  called  up 
to  her  on  the  night  of  18th  June,  1876,  "  as  she  was  suffering  acute  pain 
in  the  left  side,  which  she  could  endr.e  no  longer."  On  examining  the 
abdomen,  I  found  a  hard,  irregular,  exceedingly  tender  tumor,  from 
which  she  was  enduring  great  agony,  and  which  was  almost  as  large  as  an 
infant's  head.  I  made  tio  further  examination  that  night,  contenting 
myself  with  ordering  her  one-half  grain  morphia  suppositories,  to  relieve 
not  only  the  pain,  but  likewise  the  tenesmus  and  the  passing  of  mucus. 
The  discharge  from  the  bowels  was  quite  fluid,  but  distinctly  faecal, 
occasionally  a  scybalous  mass  making  its  appearance. 

Next  day,  the  morphia  having  taken  good  effect,  I  examined  with  the 
finger  by  the  vagina,  but  could  make  out  neither  ovarian  nor  uterine 
tumor;  the  sound  in  utero  enabled  me  to  make  certain  that  there  was  no 
intrauterine  growth;  but  movement  of  the  uterus  with  the  sound  in  the 
interior  of  it  was  attended  with  the  movement  of  the  mass,  which  I  found 
lay  outside  the  womb,  yet  connected  to  the  left  and  upper  portion  of  it — 
in  fact,  attached  to  it.  I  gave  it  as  my  opinion  that,  whatever  the  mass 
was,  it  was  outside  the  uterus,  and  was  adherent  to  it,  and  that  it  was 
not  ovarian.  I  did  not,  however,  express  the  opinion  at  which  I  arrived 
after  the  above  examinations  and  after  thoroughly  exploring  by  the 
rectum,  viz.,  that  it  was  a  case  of  impacted  and  accumulated  faeces, 
which,  having  set  up  great  irritation,  had  occasioned  inflammation,  effu- 
sion of  lymph,  and  matting  or  gluing  of  the  bowel  to  the  left  and  upper 
portion  or  cornu  of  the  uterus,  that  organ  being  still  enlarged,  its  invo- 


IMPACTED    VJBCE8    AST)   FOBEION   BODIES.  255 

lution  after  delivery  being  not  yet  completed,  probably  owing  to  the 
irritation,  inflammation,  and  subsequent  adhesion  to  which  I  have 
referred.  Taking  this  view  of  the  case,  I  purged  freely  and  continu- 
ously for  some  days,  till  at  length,  after  the  lapse  of  six  weeks,  I  had  the 
satisfaction  of  hearing  from  my  patient — for  I  did  not  attend  her  contin- 
uously during  this  period — that  the  tumor  was  all  gone,  and  she  was 
quite  well;  facts  I  verified  by  careful  manipulation  when  she  last  visited 
me.  The  iodide  of  potassium  had  been  combined  with  the  aperients,  as 
had  also  anodynes — the  former  in  hope  of  dissolving  adhesions,  the  latter 
Avith  a  view  to  ease  pain.  I  would  add,  to  show  the  difficulties  which 
sometimes  behedge  the  diagnosis  in  these  cases,  that  this  patient  had 
previously  had  pronounced  to  her  by  three  medical  men  that  operation 
alone  (gastrotomy)  could  do  her  any  good;  and  of  this  she  had  a  mortal 
dread,  so  that  all  througli  I  buoyed  her  up  with  the  hope  that  the  knife 
might  never  be  required. 

The  swelling  had  commenced  to  be  noticed  about  twelve  or  fourteen 
days  after  the  birth  of  her  child,  was  chiefly  confined  to  the  left  side, 
though  sometimes  it  seemed  to  enlarge,  and  to  extend  higher  up  and 
across  the  middle  line  towards  the  right,  and  was  so  large  that  it  was  as 
though  she  was  at  her  full  time,  and  when  walking,  even  across  her 
room,  she  required  a  towel  to  support  the  abdomen;  at  other  times  it 
would  subside,  preserving,  however,  the  same  shape;  these  alterations  in 
size  were  synchronous  with  the  action  of  the  bowels,  and  gave  me  a 
valuable  clue.  The  agony  had  been  very  great,  and  she  told  me  nothing 
had  relieved  her  for  any  length  of  time  till  she  had  used  the  morphia 
suppositories.  At  no  period  was  there  a  discharge  of  matter  indicative 
of  any  internal  abscess;  nor  any  flux  of  water  either  into  tiie  abdominal 
cavity  or  into  the  bladder,  or  any  way  externally,  which  would  demon- 
strate the  existence  and  rupture  of  an  ovarian  or  other  cystic  growth; 
therefore,  the  only  diagnosis  at  which  I  could  arrive  was  that  the  bowels 
had  become  blocked  during  the  confinement  period,  had  not  emptied 
themselves  fully,  that  an  accumulation  occurred  and  became  greater  and 
greater,  being,  however,  occasionally  partially  lessened  by  the  aperient 
action  of  the  bowels  themselves,  which  accounted  for  the  diminution  of 
and  subsidence  that  had  been  noticed  in  the  swelling. 

The  treatment  of  impaction  is  simple,  and  consists  first  of  all  in  the 
entire  removal  of  the  mass.  In  cases  of  paralysis,  where  the  accumulation 
has  not  been  allowed  to  reach  any  very  great  amount,  and  the  scybala  are 
small  and  not  very  hard,  this  may  sometimes  be  accomplished  by  the  use  of 
injections  with  a  long  tube  and  the  assistance  of  the  finger  of  the  operator. 
In  women  very  effectual  aid  may  be  rendered  under  similar  conditions  by 
pressure  from  the  vagina,  by  which  small  masses  may  be  extruded  one 
after  another,  each  with  a  certain  amount  of  pain,  but  without  laceration 
of  the  mucous  membrane  at  the  anus.  This  plan  of  treatment  will  often 
constitute  one  of  the  regirlar  duties  of  the  attendant  upon  a  case  of  paral- 


256  DISEASES    OF    THE    RECTUM    AND    ANUS. 

ysis — a  disagreeable  duty  which  must  be  attended  to  at  certain  regular 
intervals. 

In  cases  of  longer  standing,  however,  these  means  may  be  entirely  in- 
adequate and  all  injections,  no  matter  what  their  supposed  solvent  virtues 
will  be  of  no  avail  even  if  they  are  not  at  once  ejected.  In  such  cases 
the  operation  of  breaking  up  and  removing  tlie  mass  must  be  bc^un  by 
the  administration  of  ether  and  dilatation  of  the  sphincter.  This  accom- 
plished, the  mass  may  be  attacked  with  the  fingers,  an  iron  spoon,  or  a 
pair  of  lithotomy  forceps,  and  removed  piece  by  piece.  When  this  has 
been  done,  an  injection  may  be  administered  through  the  long  tube  and 
more  matter  will  generally  come  down  from  the  sigmoid  flexure.  The 
impacted  mass  is  often  as  large  as  the  fist,  and  sometimes  as  a  foetal 
head,  and  the  amount  in  the  sigmoid  flexure  and  colon  may  be  much 
greater  though  not  as  hard;  so  that  at  a  single  sitting  an  enormous 
amount  may  be  removed. 

After  such  an  operation  as  this,  the  patient  must  be  treated  by  in jec- 
tiqfis  and  a  daily  laxative,  as  will  be  described  in  speaking  of  constipation, 
till  the  over-distended  rectum  has  recovered  its  tone.  This  may  require 
a  considerable  time. 

Foreign  bodies  which  have  bee?i  swallouwd. — Medical  literature  is  full 
of  curious  cases  in  which  foreign  bodies  have  been  swallowed,  either  acci- 
dentally or  by  design,  and  have  in  some  cases  passed  the  full  length  of 
the  alimentary  canal,  and  been  safely  voided  with  the  faeces,  or  in  others 
have  become  entangled  in  the  mucous  membrane,  and  given  rise  to  much 
trouble.  Every  practitioner  is  familiar  with  cases  of  peach-stones  and 
coins  which  have  been  accidentally  swallowed,  and  knows  how  generally 
such  substances  take  care  of  themselves,  and  cause  no  symptoms  after 
once  passing  the  oesophagus.  Much  larger  substances,  such  as  whole  or 
partial  sets  of  false  teeth,  and  the  various  things  Avith  which  performers 
in  travelling  shows  entertain  an  audience,  may  also  be  passed  in  safety. 

To  show  what  nature  is  capable  of  in  this  line,  it  may  be  well  to  enu- 
merate the  substances  which  were  swallowed  and  safely  voided  by  a  cer- 
tain lunatic  now  become  famous.  The  patient  stated  that  she  had  been 
swallowing  nails,  etc.,  and  a  dose  of  castor  oil  brought  away  two  pieces  of 
faience,  one  or  two  centimetres  long  and  about  the  same  breadth,  two 
nails,  and  a  pebble.  During  the  following  six  weeks  she  passed  nineteen 
large  pointed  nails,  a  screw  seven  centimetres  long,  numerous  fragments 
of  glass  and  china,  a  piece  of  a  needle,  two  knitting  needles,  fragments 
of  whalebone,  etc.,  amounting  in  all  to  three  hundred  grammes.  During 
all  this  time  the  patient  ate  and  drank  as  usual,  and  seemed  in  ordinary 
health.' 

Prof.  Agnew  "  saw  in  the  dissecting  room  of  the  Philadelphia  School 
of  Anatomy,  a  female  subject,  afterwards  learned  to  have  been  insane,  in 

'  Lancet,  1866,  Vol.  i  ,  p.  23. 


ISCPACTED   FiECES    AND    FOREIGN    BODIES.  257 

whose  intestinal  canal  from  jejunum  to  rectum  were  found  three  spools 
of  cotton  partially  unwound;  two  roller  bandages,  one  of  them  2^  inches 
wide  and  one  inch  thick,  the  other  was  partially  unrolled,  one  end  being 
in  the  ileum,  the  other  in  the  rectum;  a  number  of  skeins  of  thread,  a 
quantity  being  packed  tightly  in  the  caecum;  and  finally  a  pair  of  sus- 
penders." 

Prof.  Gross  records  the  **  case  of  a  man  who  swallowed  a  bar  of  lead, 
ten  inches  long,  upwards  of  six  lines  in  diameter  and  one  pound  in  weight, 
whilst  performing  some  tricks  of  legerdemain,"  which  was  removed  by 
gastrotomy  and  the  patient  recovered  in  two  weeks.  He  also  mentioned 
another  cjise  in  which  a  teaspoon  was  swallowed,  whilst  the  patient  was 
in  a  paroxysm  of  delirium,  which  was  removed  from  the  ilium  by  entero- 
tomy,  recovery  taking  place  in  a  few  weeks.' 

"  Henrion,  called  Cassandra,  born  in  Metz,  in  1761.  Not  satisfied 
with  the  various  trades  which  he  followed  in  his  youth,  he  began  to 
force  himself,  at  the  age  of  twenty-two  years,  to  swallow  pebbles.  Some- 
times he  swallowed  them  whole  and  without  any  preparation,  and  some- 
times he  broke  them  between  his  teeth,  after  having  first  heated  them 
red-hot  and  then  suddenly  plunged  them  into  cold  water.  In  this 
manner  he  palmed  himself  off  as  an  American  savage.  For  several  years 
he  had  fixed  his  residence  at  Nancy,  and  there  continued  the  same 
habits  which  he  had  not  interrupted,  swallowing  daily  a  large  number  of 
pebbles,  sometimes  as  many  as  thirty  or  forty.  The  largest  pebbles 
equalled  in  volume  a  large  nut,  but  they  were  usually  smaller,  and  Hen- 
rion demonstrated  their  presence  in  the  stomach  by  the  collision  which 
he  obtained  by  percussing  the  epigastric  region.  "With  the  aid  of  salts, 
he  passed  them  in  twenty-four  hours,  and  often  made  them  do  duty  for 
the  next  day.  He  also  swallowed  live  mice,  though  only  one  in  the 
course  of  a  day,  us  well  as  crabs  of  moderate  size,  after  their  claws  had 
been  cut.  When  the  mice  were  introduced  into  the  mouth,  they  threw 
themselves  into  the  piiarynx,  in  wliich  they  were  soon  suffocated,  and 
their  deglutition  was  then  faciliUited  by  that  of  a  nail.  Upon  the  follow- 
ing day  it  was  passed  from  the  rectum,  flayed,  and  covered  with  a  mucous 
substance.  At  another  time  three  large  pennies  were  successively  put  to 
the  same  use,  and  Henrion  found  them  later,  scraped  clean  and  mixed 
with  faecal  matters. 

He  continued  this  calling  until  1820.  At  this  time  he  swallowed 
some  nails,  and  then  a  plated  iron  spoon  measuring  five  and  ahalf  inclies 
in  length  and  one  in  breadth,  for  a  moderate  sum.  He  died  seven  days 
later."' 

Napoleon  relates  a  case  of  considerable  historic  interest  where  the  ali- 
mentary canal  was  used  for  the  purpose  of  secreting  dispatches. 

'  Randolph  Winslow,  Maryland  Medical  Journal,  March,  1880. 

»  Arch.  Gen.  de  Med..  3e  Serie,  1839,  p.  353  (Poulet). 

17 


258  DISEASES    OF    THE    RECTUM    AND    ANUS. 

*'When  I  commanded  at  the  siege  of  Mantone,  shortly  before  the 
surrender  of  this  fortress,  a  German  was  arrested  while  endeavoring  to 
,  enter  the  city.  The  soldiers,  who  suspected  him  of  being  a  spy,  searched 
him  without  success;  they  then  threatened  him  in  their  own  language, 
which  he  did  not  understand.  Finally  a  Frenchman  was  called  who  spoke 
German  slightly,  and  who  threatened  him,  in  bad  German,  with  instant 
death  if  he  did  not  at  once  disclose  all  he  knew.  He  accompanied  this 
threat  with  furious  gestures,  drew  his  sword,  placed  the  point  of  it  upon 
his  belly,  and  said  he  was  going  to  slit  him  open.  The  poor  German, 
frightened  and  not  understanding  the  jargon  of  the  French  soldier, 
imagined,  when  he  saw  him  threatening  his  belly,  that  his  secret  was  dis- 
closed, and  cried  out  that  it  was  unnecessary  to  slit  him  open,  and  that 
if  he  waited  a  few  hours  it  could  be  obtained  in  the  natural  manner. 
This  gave  rise  to  fresh  questions;  he  stated  that  he  was  the  bearer  of  dis- 
patches for  Wurmser,  and  that  he  had  swallowed  them  as  soon  as  he  found 
himself  in  danger  of  being  captured.  He  was  carried  to  my  headquarters, 
whither  several  physicians  were  summoned.  It  was  proposed  to  admin- 
ister a  purgative,  but  they  stated  that  it  was  best  to  await  the  operation 
of  nature.  He  was  then  confined  to  a  room  under  the  surveillance  of  two 
staff  officers,  one  of  whom  was  constantly  near  him.  After  several  hours 
the  expected  object  was  found.  It  was  inclosed  in  wax,  and  was  as  large 
as  a  nut.  "When  opened  it  was  found  to  be  a  dispatch  written  in  the 
hand  of  the  Emperor  Francis,  and  which  requested  him  not  to  be  dis- 
couraged and  to  hold  out  a  few  days  longer,  when  he  would  aid  him 
with  a  strong  column."  Napoleon,  upon  these  indications,  left  with  his 
troops  and  completely  defeated  Alvinzi  at  the  passage  of  the  P6. 

It  would  be  beyond  the  scope  of  a  work  such  as  this  to  attempt  to  deal 
with  the  whole  question  of  foreign  bodies  in  the  alimentary  canal,  and 
the  accidents  which  may  attend  them.  In  a  general  way,  the  prognosis 
is  good  unless  the  foreign  body  be  a  very  ragged  one  or  a  large  sharp  one 
like  a  fork;  and  the  treatment  consists  in  giving  a  diet  like  bread  and 
fruit,  which  will  cause  copious  stools,  with  little  drink,  and  the  avoidance 
of  exercise  such  as  walking.  If  complications  arise,  they  must  be  treated 
on  general  surgical  principles;  and  at  the  present  day  no  patient  would  be 
allowed  to  die  from  the  effects  of  a  foreign  substance  in  the  stomach  or 
intestines  without  a  surgical  operation  for  its  removal,  provided  only  the 
diagnosis  were  clear. 

The  complications  which  may  attend  the  detention  of  such  substances 
in  the  rectal  pouch  just  above  the  internal  sphincter  are  ulceration  with 
perforation,  haemorrhage,  and  abscess.  ■  Ulceration  may  be  caused  by  the 
pressure  of  a  large  body,  and  may  cover  a  considerable  space,  or  it  may 
be  caused  by  the  pressure  of  the  sharp  ends  of  a  smaller  body,  in  which 
case  the  spots  of  ulceration  will  be  smaller,  and  may  be  located  at  two 
opposite  points  in  the  rectum.     As  a  result  of  ulceration,  there  will  be 

'  Memorial  de  Sainte  Helene,  t.  ii.,  p.  468  (Poulet), 


IMPACrKD    Fi1£CE8    JlSD    FOREIGN    BODIS8.  259 

more  or  less  pain,  purulent  discharge,  and  perhaps  also  a  sharp  haemor- 
rhage from  the  erosion  of  a  vessel.  When  perforation  of  the  wall  of  tlie 
bowel  has  occurred,  inflammatory  action  is  almost  sure  to  be  excited  in 
tlie  surrounding  parts,  and  this  may  vary  greatly  in  its  extent  and  grav- 
ity. If  the  injury  be  above  the  point  of  reflection  of  the  peritoneum,  it 
may  cause  either  a  localized  or  a  general  peritonitis.  A  general  peritoni- 
tis caused  in  this  way  will  be  fatal,  as  it  is  also  generally  accompanied  by 
more  or  less  extravasation  of  faeces.  A  circumscribed  peritonitis  with 
formation  of  an  abscess  is  a  less  fatal  complication.  Under  these  circum- 
stances the  usual  signs  of  pelvic  abscess  will  be  present — fever,  pain  on 
pressure,  tympanites,  painful  defecation  and  urination — and  by  careful 
examination  a  tumor  may  bo  discovered,  either  through  the  rectum  or  at 
the  bottom  of  the  iliac  fossa.  Such  cases,  when  the  tumor  is  on  the  right 
side,  are  often  mistaken  for  cases  of  perityphlitis,  but  the  tumor  is  not 
in  the  same  location.     It  is  deeper  and  nearer  the  median  line. 

Such  an  inflammation  may  terminate  in  resolution,  provided  the 
cause  be  discovered  and  removed;  but  the  usual  termination  is  in  suppu- 
ration, and  the  pus,  if  not  removed  by  the  surgeon,  may  find  its  way  into 
the  general  peritoneal  cavity  or  into  the  bladder  or  rectum.  Abscesses  of 
the  superior  pelvi-rectal  space  have  already  been  described,  and  those 
which  are  due  to  foreign  bodies  in  the  bowel  do  not  differ  from  them  in 
general  characters. 

Spontaneous  cure  may  follow  the  rupture  of  such  an  abscess  into  the 
rectum  or  bladder,  but  an  incurable  fistula  is  more  apt  to  result  even  after 
the  foreign  body  has  been  discharged.  In  one  such  case  I  was  able  to 
withdraw  the  pus  through  the  abdominal  wall  with  the  aspirator,  and 
subsequently,  when  the  abscess  cavity  again  filled  up,  1  incised  it  through 
the  rectum  just  behind  the  prostate.  This  opening  was  kept  from  clos- 
ing by  the  daily  introduction  of  the  end  of  the  index-finger,  and  the  ab- 
scess finally  healed  very  kindly — a  result  which  was  in  great  measure  due 
to  the  fact  that  the  patient  was  a  child  of  twelve  years,  and  not  an  adult. 

Wlien  the  focus  of  inflammation  is  located  below  the  reflection  of  the 
peritoneum,  the  prognosis  is  less  grave.  Phlegmonous  abscess  may  form 
in  the  ischio- rectal  fossa,  and  must  be  treated  according  to  the  rules 
already  laid  down;  but  here  the  dififlculty  is  well  within  the  reach  of  the 
surgeon,  and  a  cure  may  confidently  be  looked  for  by  proper  care. 

Foreign  bodies  introduced  per  anum. — A  classification  of  these  cases 
is  useless.  The  foreign  bodies  may  be  introduced  through  traumatism: 
by  the  patient  in  an  honest  endeavor  to  relieve  himself  of  piles  or  pro- 
lapse; by  the  surgeon  for  the  purpose  of  relieving  rectal  disease.  They 
are  often  introduced  in  a  spirit  of  revenge  or  of  trickery;  and  most  often 
of  all  they  are  lost  m  the  practice  of  an  unnatural  vice.  Edward  II.  is 
said  to  have  met  his  death  by  having  a  red-liot  iron  thrust  into  the  rec- 
tum. ["We  seized  the  king,"  said  one  of  the  murderers,  "and  threw 
him  forcibly  upon  the  couch,  and,  whilst  I  kept  him  there  by  the  assist- 


260  DISEASES    OF    THE    RECTUM    AND    ANUS. 

anoe  of  a  table,  with  a  pillow  on  his  face,  Gurney  inserted  through  a  liorn- 
tube  a  red-hot  iron  into  his  bowels."     Gross,  Vol.  ii.,  p.  627.] 

The  case  of  the  prostitute  into  whose  rectum  the  students  of  the  Uni- 
versity of  Gottingen  introduced  a  pig's  tail,  butt  end  first,  is  as  follows: 

''Some  students  had  formed  the  plan  of  playing  a  practical  joke  on 
a  prostitute;  they  determined  to  push  into  her  anus  a  frozen  pig's  tail. 
They  cut  the  hairs  very  short  in  order  to  make  them  sharper  and  rougher, 
then  dipped  it  in  oil,  and  forcibly  introduced  it  into  the  woman's  anus, 
with  the  exception  of  a  portion  three  fingers'  breadth  in  length,  which 
remained  outside.  Several  attempts  were  made  to  extract  it,  but,  as  it 
could  only  be  withdrawn  against  the  hairs,  the  bristles  entered  against 
the  mucous  membrane,  and  gave  rise  to  excruciating  pain.  In  order  to 
relieve  it,  various  oily  remedies  were  given  by  the  mouth,  and  the  attempt 
was  made  to  dilate  the  anus  with  a  speculum  in  order  to  extract  the 
tail  without  violence,  but  it  was  unsuccessful.  Severe  symptoms  devel- 
oped, violent  vomiting,  obstinate  constipation,  very  high  fever,  and 
intense  pains  in  the  abdomen.  Marchettis  was  summoned  on  the  sixth 
day.  This  physician,  having  been  informed  of  what  had  happened,  in- 
vented a  very  simple  and  ingenious  device.  He  took  a  hollow  reed,  one 
end  of  which  he  prepared  so  that  he  could  easily  introduce  it  into  the 
anus,  and  completely  inclosed  the  pig's  tail  in  this  reed,  in  order  to  with- 
draw it  without  pain.  For  this  purpose  he  attached  to  the  tail,  by  the  end 
which  projected  from  the  anus,  a  stout  wax  thread  which  he  passed  into 
the  reed.  With  one  hand  he  pushed  this  form  of  canula  into  the  rec- 
tum, and  held  the  cord  in  the  other,  to  prevent  the  tail  being  pushed  in 
still  further.  He  succeeded  in  completely  inclosing  the  tail,  and  promptly 
relieved  the  patient.'" 

A  punishment  for  adultery  among  the  Greeks  is  said  to  have  been  the 
introduction  into  the  rectum  of  a  peeled  radish,  covered  with  hot  ashes; 
and  cases  in  which  patients  have  fallen  upon  shai'p  and  fragile  objects, 
such  as  the  wooden  pickets  of  a  fence,  which  have  broken  off  and  re- 
mained in  the  rectum,  are  on  record. 

The  list  of  foreign  bodies  which  have  been  lost  in  the  rectum  by  ignor- 
ant persons,  in  attempts  to  check  a  diarrhoea  or  to  prevent  the  descent  of 
piles  or  prolapse,  is  a  very  long  one,  and  includes  such  substances  as  bot- 
tles, sticks  of  wood,  and  round  stones,  some  of  them  of  a  size  relatively 
enormous;  and  the  use  of  the  rectal  pouch  by  criminals  for  the  purposes 
of  concealment  is  well  known  to  the  police. 

In  the  Museum  of  Anatomy  and  Pathology,  at  Copenhagen,  is  a  long- 
ish  oval  flat  stone,  about  6f  inches  loiig,  2^  inches  wide,  1^  inches  thick, 
and  weighing  nearly  two  pounds,  which  a  patient  in  Bornholm  intro- 
duced into  his  rectum  to  prevent  prolapse,  from  which  he  had  for  a  long 


>  Hevin,  p.  839. 


DCPAOTED   VM0E8    AKD   FOREIOX    BODIES.  261 

time  suffered.     The  stone  was  extracted  by  a  surgeon,  Frantz  Dyhr,  in 
1756.' 

Real*  operated  in  1849,  in  the  hospital  at  Orvieto,  on  a  peasant  who 
nine  days  previously  had  introduced  a  piece  of  wood  into  the  rectum 
for  the  purpose,  as  he  said,  of  economizing  his  food,  and  preventing  it 
from  passing  out  too  quickly.  He  had  violent  pain.  On  exploration, 
the  finger  could  feel  the  base  of  the  piece  of  wood  lying  in  the  hollow  on 
the  sacrum,  and  surrounded  by  the  broken  mucous  membrane.  As  re- 
]>eated  attempts  at  extraction  led  to  no  result,  Reali  made  an  incision  in 
the  right  iliac  region,  and  found  that  the  foreign  body  lay  in  the  sigmoid 
flexure,  which  it  had  dilated  and  pushed  to  the  middle  line  nearly  as 
far  as  the  umbilicus;  he  incised  the  intestine,  removed  the  foreign  body, 
and  closed  the  intestinal  wound  by  Jobert's  method.  The  patient  was 
treatec"  by  purgatives  (I)  and  had  cntero-peritonitis  and  abscess  in  the 
iliac  fossa,  but  recovered,  and  two  years  afterwards  was  in  perfect  health. 
The  foreign  body  was  a  piece  of  chestnut  wood  of  the  shape  of  a  trun- 
cated cone,  10  inches  long,  and  about  3^  or  4  inches  in  diameter. 

A  little  case  with  very  ingenious  housebreaking  and  other  thieves'  in- 
struments was  found  by  Dr.  Closmadeuc  at  the  necropsy  of  a  man  if 
the  prison  at  Vennes.  The  man  had  died  of  acute  i:>eritonitis,  from 
which  he  had  suflEered  seven  days.  During  his  illness,  a  hard,  rather 
large  body  was  felt  in  the  left  side  of  the  hypogastrium;  he  said  that  it 
w:i8  a  piece  of  wood  containing  money,  which  he  had  introduced  into  the 
rectum;  this,  on  exploration  in  tlie  mean  time,  was  found  empty.  On 
section,  the  case,  which  was  cylindro-conical  in  form,  lay  in  the  trans- 
verse colon,  with  its  apex  directed  towards  the  caecum;  it  was  of  iron,  and 
was  wrapped  in  a  piece  of  lamb's  mesentery;  it  weighed  about  23  ounces, 
W!is  about  6^  inches  long,  and  5^  in  circumference,  and  contained  13 
tools  and  some  coins.* 

*'A  mcnk,  desiring  relief  from  a  severe  colic  from  which  he  was  suf- 
fering, was  advised  to  introduce  into  the  rectum  a  bottle  of  Hungary 
water,  in  the  cork  of  which  there  was  a  small  opening,  through  whicli 
the  water  gradually  distilled  into  the  intestine  (these  bottles  are  usually 
long).  He  pushed  it  so  far  that  it  entered  the  rectum  altogether,  whereat 
he  was  greatly  astonished.  He  could  neitlier  have  an  evacuation  nor 
receive  an  enema,  inflammation  and  death  were  apprehended.  A  mid- 
wife was  consulted  in  order  to  see  whether  she  could  introduce  her  fin- 
ger and  extract  the  bottle,  but  she  was  unable  to  do  it.  Forceps,  a 
ri]>ping-iron,  and  anal  sjmjcuIjk  were  useless.  It  could  not  be  broken; 
this  would  have  Ijeen  more  disastrous  as  the  pieces  of  glass  would  have 
wounded  him.     Finally,  a  little  boy,  eight  or  nine  years  old,  was  found, 

•  Bull,  de  la  Soc.  de  Chir.,  1878,  p.  660. 

*  London  Med.  Record,  Dec.  15th,  1878.  Abstract  of  Studsgaard's  paper  read 
l>efore  Soc.  de  Chir.,  Paris,  Oct.  9th,  1878. 


262  DISEASES    OF    THE    RECTUM    AND    ANUS. 

who  introduced  his  hand,  and  had  sufficient  address  to  cure  the  good 
monk."  ' 

A  depraved  sexual  appetite  has  been  mentioned  as  accounting  for  the 
presence  of  many  foreign  bodies.  It  is  known  that  sexual  orgasm  may 
be  excited  by  stimulating  the  reflex  power  of  the  rectum,  and  it  is  prob- 
able that  at  the  moment  when  the  orgasm  is  at  its  height,  the  body  used 
to  produce  it  is  allowed  to  escape  from  the  hand  and  is  lost  within  the 
bowel.  This  is  a  habit  which  will  never  be  acknowledged  by  its  victims, 
but  which  may  often  be  assumed  to  exist  by  the  surgeon  in  depraved 
patients.  The  bodies  used  for  this  purpose  are  generally  smooth,  long, 
and  round,  such  as  glass  bottles,  and  pieces  of  wood.  The  following  case- 
is  one  in  point,  and  the  age  of  the  patient  is  suggestive,  for  this  vice  is 
said  to  be  more  common  in  old  men  than  in  others — men  whose  physical 
powers  have  not  kept  pace  with  their  desires. 

"  On  the  afternoon  of  March  1st,  1848,  a  young  man  consulted  Par- 
ker with  regard  to  his  father,  whom  he  had  brought  into  the  hospital. 
After  beating  around  the  bush  and  manifesting  considerable  shame  and 
embarrassment,  he  stated  that  his  father,  named  Loo,  who  was  sixty 
years  old,  had  passed  the  previous  night  in  a  house  of  prostitution. 
Overcome  by  drink  and  opium,  the  old  debauchee  conceived  the  strange 
notion  of  pushing  a  goblet,  two  and  a  half  inches  in  diameter  and  three 
and  a  half  inches  long,  into  the  vagina  of  his  partner.  During  the  niglit, 
while  Loo  was  completely  intoxicated,  the  woman  attempted  to  revenge 
herself.  She  carefully  introduced  the  bottom  of  the  goblet  into  the  rec- 
tum, placed  the  end  of  the  opium  pipe,  which  was  a  foot  and  a  half 
long,  into  the  goblet,  and  pushed  it  into  the  rectum.  The  goblet  dis- 
appeared and  had  been  retained  twenty-four  hours.  A  piece  of  the  edge, 
about  half  an  inch  long,  had  been  broken  off  by  the  friends  in  attempts 
at  extraction.  The  glass  was  firmly  fixed,  and.it  was  very  difficult  to 
pass  the  finger  between  it  and  the  rectum.  Parker,  determining  to  break 
it,  employed  a  cephalotribe  and  removed  it  in  pieces,  taking  care  to  pro- 
tect the  parts  with  cotton.  The  most  difficult  part  was  the  extraction  of 
the  glass,  which  was  very  irritating.  It  was  done,  but  not  without  diffi- 
culty, by  making  it  see-saw  from  side  to  side.  Considerable  haemorrhage 
occurred,  which  was  arrested  with  sulphate  of  copper  and  alum.  The 
man  recovered  in  two  weeks.  "^ 

It  would  be  interesting  to  enumerate  the  foreign  bodies  which  have 
been  removed  from  this  part  of  the  body  and  the  list  would  be  startling 
from  the  strangeness  of  the  different  articles;  but  enough  has  been  said 
•  to  indicate  that  almost  anything  from*a  conical  stone  to  a  club  or  a  coffee 
cup  may  be  encountered  by  the  surgeon,  and  to  indicate  the  size  of  the 
body  which  the  sphincter  will  allow  to   pass.     Among   them   may  bo 

'  Mem.  de  I'Acad.  de  Chirurgie. 

"^  Amer.  Journ.  of  the  Medical  Sciences,  1849,  p.  409. 


IMPACTED    FJECKS    AND    FOREIGN    BODIES.  263 

mentioned  beer  glasses,  muslirooui  bottles,  wooden  pepper  boxes,  wine 
bottles  of  all  kinds,  lamp  chimneys,  and  a  part  of  the  wooden  handle  of 
a  baker's  shovel  twenty-two  centimetres  in  length. 

A  foreign  substance  may  remain  in  the  rectum  for  a  considerable  time 
and  finally  be  expelled  spontaneously  as  in  the  following  case  reported  by 
Weigand.' 

"A  farmer,  aged  sixty-eight  years,  of  a  robust  constitution,  but 
somewhat  stupid,  introduced  into  the  anus  a  cylindrical  piece  of  wood 
for  the  purpose  of  relieving  his  obstinate  constipation.  However,  he 
performed  the  manipulation  so  unskilfully  that  the  piece  of  wood  broke 
and  remained  partly  within  the  rectum.  All  attempts  made  to  remove 
the  foreign  body  failed;  two  days  later,  he  suffered  from  abdominal  and 
lumbar  pains,  dysuria,  and  constipation.  Weigand  being  consulted  by 
the  physician,  recognized  the  symptoms  of  enteritis.  As  the  introduc- 
tion of  a  finger  into  the  rectum  did  not  demonstrate  the  presence  of  a 
foreign  body,  he  restricted  himself  to  combating  the  inflammatory  symp- 
toms and  pain  (calomel,  enemata,  narcotics,  leeches).  On  the  eleventh 
day  a  purulent,  sanguinolent,  fetid  fluid  was  evacuated,  after  which  the 
patient  felt  markedly  relieved;  but  it  was  impossible  to  discover  any 
trace  of  the  piece  of  wood.  Weigand  then  expressed  serious  doubts  as  to 
whether  a  foreign  body  was  really  contained  in  the  rectum;  but  as  the 
patient  resolutely  maintained  that  he  continued  to  feel  the  piece  of 
wood,  renewed  search  was  made,  until  the  finger  being  introduced  far  in, 
encountered  a  rough,  hard  object  which  it  was  impossible  to  seize  for 
want  of  proper  instruments.  As  circumstances  did  not  indicate  a  neces- 
sity for  more  active  treatment,  Weigand  contented  himself  with  giving 
the  patient  from  time  to  time  two  or  three  spoonfuls  of  castor-oil  which 
always  produced  the  discharge  of  a  small  amount  of  muco-sanguinolent 
fxcQS.  At  this  time  the  lumbar  and  abdominal  pains  again  appeared 
more  frequently,  and,  on  the  other  hand,  the  patient's  former  appetite 
being  gradually  restored,  he  walked  about  and  attended  to  light  domestic 
duties.  On  the  31st  day  after  the  accident,  after  having  taken  three 
spoonfuls  of  castor-oil,  he  stated  that  he  had  an  intense  desire  to  go  to 
stool,  when  in  addition  to  blood  and  pus,  the  piece  of  wood  made  its  ap- 
pearance, 0.1357  m.  long,  0.027  thick,  cylindrical,  serrated  at  the  broken 
end,  and  roughened  on  the  cylindrical  surface;  in  fact  it  was  the  end  of 
a  pole  with  which  bean-vines  are  propped.  The  patient  recovered  en- 
tirely without  having  been  subjected  toany  further  treatment "  (Poulet). 

Prognosis. — The  j)rognosi8  in  cases  of  foreign  bodies  will  depend 
greatly  upon  their  size  and  nature.  A  long  body  like  a  piece  of  wood 
may  go  so  far  up  the  bowel  as  to  do  fatal  damage  before  its  removal;  and 
a  fragile  body  like  glass  may  cause  fatal  injury  in  the  attempt  to  remove 
it.     Again  the  prognosis  depends  in  great  measure  upon  the  surgical 

'  Schmidt's  Annalen,  113, 'iv.,  p.  95,  1862. 


264  DISEASES    OF   THE    RECTUM    AND    ANUS. 

ability  of  the  one  in  charge  of  the  case.  A  little  bungling  in  the  treat- 
ment may  at  any  moment  change  a  case  which  promises  well  into  a  fatal 
one.  Finally,  much  will  depend  upon  the  length  of  time  during  which 
the  body  has  remained  in  the  rectum;  and  it  is  not  yery  uncommon  for 
patients  who  have  met  with  an  accident  in  the  practice  of  this  secret 
vice  to  conceal  the  real  nature  of  the  trouble  which  they  well  understand 
till  they  are  forced  by  suffering  to  confess.  In  this  way  a  week's  valu- 
able time  may  be  lost  and  a  fatal  amount  of  injury  be  done. 

Treatment. — Each  case  of  foreign  body  must  be  treated  by  itself,  and 
besides  a  few  general  principles  which  apply  equally  to  all  cases,  the 
surgeon  will  be  left  entirely  to  his  own  ingenuity.  The  one  guiding  prin- 
ciple should  be  to  avoid  doing  fresh  injury  in  the  attempt  at  removal. 
Only  the  smaller  and  least  friable  of  bodies  can  be  removed  without  a 
previous  dilatation  of  the  sphincter  under  ether,  and  in  most  cases  it  will 
be  advisable  to  incise  the  anus  in  the  median  line  down  to  the  tip  of  the 
coccyx  as  a  preparatory  measure  to  all  treatment.  This  step  will  some- 
times render  a  body  movable  which  before  was  absolutely  immovable  and 
thus  open  the  way  for  its  extraction. 

Having  opened  the  way  to  the  body,  it  may  sometimes  be  removed  by 
passing  the  whole  hand  into  the  rectum,  and  seizing  it.  At  other 
times  forceps  may  be  used  with  advantage  and  these  maybe  of  any  shape 
which  seems  best  to  answer  the  purpose  intended,  including  the  obstetric 
forceps  which  have  been  found  useful  in  many  cases.  If  a  bottle  has 
been  introduced  with  the  mouth  downward  a  string  may  be  secured 
around  the  neck  for  the  purpose  of  traction,  but,  unfortunately  in  almost 
all  cases  the  position  will  be  reversed.  In  cases  of  long  bodies  the  lower 
end  is  not  infrequently  firmly  wedged  in  the  hollow  of  the  sacrum — so 
firmly  as  to  resist  all  efforts  at  dislodgment.  Under  such  circumstances 
fatal  injury  may  easily  be  done  by  the  operator  by  persistence  in  the  attempt. 

Above  all  things  the  surgeon  must  avoid  breaking  such  a  substance  as 
a  cup,  for  experience  has  proved  that  after  this  has  happened,  removal 
without  causing  great  injury  is  almost  impossible. 

Certain  complications  may  at  any  time  arise  in  the  treatment  of  these 
cases,  one  of  which  is  recorded  by  Desault. '  A  man,  aged  forty-seven 
years,  entered  the  Hotel  Dieu,  on  April  17th,  1762,  in  order  to  have  a 
crockery  vessel  extracted  from  his  rectum,  which  he  had  introduced  a 
week  previously  in  order  to  overcome,  as  he  said,  his  obstinate  constiija- 
tion.  This  vessel  was  a  preserve  jar,  the  handle  of  wliich  was  broken 
and  the  bottom  detached.  It  was  conical  in  shape,  and  three  inches 
long;  it  had  been  introduced  by  the  smaller  end,  which  was  two  inches  in 
diameter. 

When  the  patient  presented  himself  at  the  hospital^  he  had  already 
made  efforts  to  extract  the  foreign  body,  but  an  escape  of  blood  and  the 

•  Journal  de  Chir.,  T.  iii.,  p.  177  (Poulet). 


IMPACTED    F^BOES    AND   FOBBION   BODIB8.  265 

excessive  pains  had  compelled  him  to  suspend  his  efforts.  The  upper 
part  of  the  rectum  was  infolded  and  invaginated  in  the  vessel,  and  formed 
a  very  hard  tumor,  which  filled  it  completely.  The  surrounding  parts 
were  inflamed,  and  this  fact  rendered  the  extraction  more  difficult. 
Dcsault  made  the  patient  lie  upon  the  side,  and  then,  separating  the  in- 
testine from  the  walls  of  the  vessel,  he  succeeded  in  seizing  the  latter 
with  a  strong  extractor,  which  he  pushed  up  as  far  as  possible  and  which 
was  held  by  an  assistant.  By  means  of  this  point  of  support,  and  with 
another  extractor  introduced  in  the  same  manner,  he  succeeded  in  break- 
ing the  vessel  and  in  extracting  it  in  small  pieces  without  wounding  the 
rectum.  Tiie  operation  was  neither  long  nor  painful,  though  it  was 
necessary  to  introduce  the  extractors  a  large  number  of  times.  After  all 
the  pieces  had  been  removed,  Desault  pushed  back  the  inverted  portion 
of  tlie  rectum  by  means  of  a  cha'rpie  tampon  six  inches  long  and  two  and 
a  half  in  diameter,  which  he  pushed  in  altogether  after  having  covered  it 
with  cerate.  Below  this  were  placed  a  large  amount  of  charple,  several 
compresses,  and  a  triangular  bandage  which  supported  the  whole  dress- 
ing. The  dressing  was  renewed  twice  a  day,  on  account  of  the  relaxation 
which  did  not  cease  till  the  sixth  day.  Then  the  intestine  no  longer  pro- 
truded when  the  patient  went  to  stool,  and  such  large  tampons  were  not 
required.  They  were  discontinued  entirely  after  the  tenth  day,  when  the 
ruptures  had  cicatrized,  and  the  man  left  the  hospital  entirely  cured  two 
weeks  after  the  operation. 

In  cases  where  a  long  body  has  become  firmly  wedged  into  the  lower 
end  in  tlie  hollow  of  the  sacrum,  the  proper  treatment  consists  in  opening 
the  abdomen  and  this  should  be  done  after  an  attempt  to  remove  it  per 
anum  has  been  continued  a  reasonable  time,  and  before  injury  has  been 
done  in  such  an  attempt.  It  is  not  necessary  to  describe  the  operation  of 
laparo-enterotomy  in  this  connection.  The  incision  may  be  made  either 
in  the  median  line  or  in  the  groin.  In  the  Surgical  History  of  the  War 
of  the  Rebellion,  T.  II.,  p.  322,  there  is  a  history  of  one  such  operation 
performed  upon  a  sailor  who  liad  introduced  a  stone  five  and  a  quarter 
inches  long  by  three  wide.  The  colon  had  been  perforated  and  the  stone 
was  removed  from  the  peritoneal  cavity  by  an  incision  near  the  umbilicus. 
The  man  recovered.  The  oldest  known  case'  Wiis  reported  by  Realli  in 
the  Bull,  dei  Soc.  Medich.,  and  Gaz.  Med.,  July,  1851,  and  is  as  follows  : 

Case  XXV. — "  On  the  18th  of  December,  1848,  a  peasant  was 
brought  in  the  hospital  of  Orvieto  in  a  condition  of  extreme  weakness. 
Nine  days  previously,  having  hit  upon  the  ingenious  idea  that,  if  he  pre- 
vented the  discharge  of  food  he  could  limit  the  quantity  to  beswallowed, 
he  introduced  a  piece  of  wood  into  the  rectum;  all  his  attempts  at  re 

'  For  this  and  many  other  interesting  facts  in  connection  with  this  subject  the 
reader  is  referred  to  Poulet's  work  on  "  Foreign  Bodies  in  Surgery."  Wood's 
JLibrary  of  Standard  Medical  Authors,  1880. 


266  DISEASES    OF    THE    RECTUM    AND    ANUS. 

moval  only  served  to  push  it  in  still  further.  The  finger  could  only 
touch  the  end  of  the  object  and  it  was  firmly  fixed  in  such  a  manner  as 
not  to  yield  to  any  tractions  which  could  be  made  upon  it  witli  sucli  a 
slight  purchase. 

After  the  failure  of  all  attempts  at  removal,  the  foreign  body  com- 
pletely obliterating  the  intestinal  cavity,  and  the  patient  being  threatened 
with  death  from  his  atrocious  sufferings,  Eealli  decided  to  operate. 
After  having  cut  the  abdominal  walls  on  the  left  side,  he  could  distinctly 
feel  the  stake  in  the  descending  colon.  He  desired  to  push  it  down  to 
the  anus,  but  the  attempts  proved  unsuccessful,  and  he  was  compelled  to 
incise  the  intestine.  Only  after  this  was  done  could  he  remove  the  body, 
which  was  ten  centimetres  long  and  more  than  three  centimetres  in 
diameter  at  the  base.  The  point  was  rounded  and  very  soft.  No  faeces 
were  retained  above  the  plug,  but  the  mucous  membrane  was  blackish, 
the  peritoneal  coat  strongly  injected,  and  the  thickness  of  the  intestinal 
wall  markedly  increased. 

The  wound  in  the  intestine  was  united  by  a  suture,  which  was 
applied  according  to  Jobert's  plan.  The  lips  of  the  wound  in  the 
abdomen  were  united  by  means  of  an  interrupted  suture.  Cold,  and 
then  iced  applications  were  made  over  the  operated  region.  Two  doses 
of  castor-oil  were  administered.  There  was  a  purulent  discharge  from 
the  anus.  During  the  first  few  days,  the  tumefaction  of  the  walls  of  the 
intestines  prevented  the  advance  of  faeces,  and  caused  meteorism  and 
vomiting.  Three  bleedings,  two  applications  of  leeches,  and  a  few  doses 
of  castor-oil  put  an  end  to  these  symptoms,  which  had  acquired  an 
alarming  character.  The  evacuations  from  the  bowels  were  again  passed 
on  the  fifth  day.  Towards  the  fourteenth  day,  the  wounds  had 
cicatrized.     Two  years  later,  the  health  remained  perfect." 

In  a  paper  read  before  the  Soc.  de  Chirurgie,'  Studsguard,  of  Copen- 
hagen, reports  the  following  similar  case: 

Case  XXVI, — "  J.  F.,  footman,  aged  thirty-five  years,  was  admitted 
on  January  10th,  1878,  to  the  Copenhagen  hospital,  and  left  cured  on 
April  16th,  1878.  The  night  before  entering,  he  had  introduced  an 
empty  mushroom  bottle  into  the  rectum,  the  neck  of  the  bottle  being 
uppermost,  in  order,  as  he  stated,  to  relieve  a  rebellious  diarrhoea,  and  on 
the  morning  of  January  10th,  he  was  obliged  to  call  a  physician,  acute 
pains  being  experienced  in  the  abdomen. 

He  was  anaesthetized  with  chloroform,  but  the  bottle,  which,  previous 
to  the  narcosis,  had  been  felt  in  the  rectum,  slipped  further  up.  He 
was  exhausted  by  the  passage  and  the  increasing  pains;  vomiting  of 
mucus.  The  bottle  could  be  felt  through  the  somewhat  tense  abdominal 
wall  along  the  median  line  on  the  left  side,  the  bottom  being  near  the 


'  Bull,  de  la  Soc.  de  Chir.,  1878,  p.  663. 


IMPACTED    rJECES    AND    FOREIGN    BODIES.  267 

horizontal  ramus  of  the  pubis.  In  the  evening,  profound  narcosis  and 
l)08terior  linear  rectotomy;  the  hand  was  introduced  as  far  as  the  third 
sphincter,  which  was  not  forced,  on  account  of  its  resistance.  The 
bottle  was  then  pressed  from  the  outside  down  into  the  pelvis,  but  it  de- 
scended in  a  loop  of  the  intestine  in  front  of  the  rectum.  Immediately 
afterward,  antiseptic  laparo-enterotomy,  through  the  median  line,  by  an 
incision  ten  centimetres  long,  commencing  at  the  umbilicus.  A  loop, 
which  was  thought  to  be  the  sigmoid  flexure,  was  extracted,  and  the 
bottle  was  then  slowly  removed  through  an  incision  four  centimetres 
long,  which  was  made  upon  the  orifice  and  upper  part  of  the  neck.  The 
entire  circumference  was  protected  by  sponges  and  compresses  between 
the  faeces,  and  the  intestinal  incision  was  closed  by  twelve  to  fourteen 
catgut  sutures,  according  to  Lambert's  method,  the  peritoneal  sui-faces 
having  been  freely  washed.  In  order  to  be  on  the  safe  side,  the  sutures 
were  tied  with  three  knots;  the  intestines  were  then  introduced,  and  the 
abdominal  wound  united  with  eight  silk  sutures,  tied  alternately  with 
knots  and  the  figure  of  eight. 

The  operation  histed  an  hour. 

The  bottle  was  seventeen  centimetres  long,  the  diameter  of  the 
bottom  was  five  centimetres,  that  of  the  neck  three  centimetres;  the 
opening  contained  a  notch,  which  was  evidently  of  old  date,  about  half  a 
centimetre  long,  and  presenting  cutting  edges.  The  recovery  occupied 
a  long  time,  and  the  prognosis  was  uncertain  for  a  very  protracted 
j>eriod,  on  account  of  a  local  peritonitis  with  abscess  formation,  which 
I  incised  both  upon  the  median  line  and  through  the  rectum,  upon  the 
posterior  wall  of  which  it  projected.  Gas  began  to  pass  two  days  after 
the  operation;  from  the  ninth  day  on,  he  had  spontaneous  evacuations,, 
which  were  well-formed,  and  contained  no  traces  of  pus." 

One  other  case  of  this  kind  has  been  placed  on  record'  by  Vemeuil, 
and  those  four,  I  believe,  make  up  all  the  literature  of  the  subject. 

Case  XXVII. — A  man,  aged  forty-five,  had  been  in  the  habit  of 
stopping  up  his  rectum  to  overcome  an  incontinence  of  faeces  which  had 
resulted  from  two  previous  attacks  of  dysentery.  For  this  purpose,  he 
used  various  large  bodies,  taking  the  precaution  to  tie  to  them  a  piece  of 
cord,  the  ends  of  which  were  left  hanging  outside.  But  one  day,  he  had 
no  cord,  and  a  cylindrical  piece  of  wood,  ten  centimetres  long  and  about 
eight  in  diameter,  escaped  into  the  upjKjr  part  of  the  rectum,  and  could 
neither  be  forced  down  nor  reached  with  tlie  finger.  All  the  efforts 
which  were  immediately  made  by  a  physician  of  the  place  only  forced  tiie 
body  further  from  the  anus. 

In  this  condition,  the  patient  entered  the  service  of  M.  Verneuil.  There 
were  few  signs  of  retention,  but  the  finger  could  not  be  made  to  reach 
the  foreign  body;  only  with  the  hand  on  the  abdomen  could  it  be  felt  in 

'  Prog.  Med.,  May  15th,  1880. 


268  DISEASES    OF    THE    KECTUM    AND    ANUS. 

the  left  iliac  fossa.  It  was  so  high  that  linear  proctotomy  could  give  no 
assistance,  and  therefore  laparotomy  was  decided  upon.  The  plan  of 
operation  was  the  following:  Through  a  small  abdominal  incision  to 
search  for  the  sigmoid  flexure,  in  which  the  body  was  probably  lodged; 
to  draw  the  sigmoid  flexure  outward,  and,  if  healthy,  to  incise  it,  remove 
the  body,  sew  up  the  gut,  and  replace  it  in  the  abdomen.  If,  on  the 
contrary,  it  was  diseased,  to  stitch  it  to  the  abdominal  wall,  and  make  an 
artificial  anus.  But  the  foreign  body  was  so  fixed  in  the  npper  part  of 
he  rectum,  with  its  long  axis  from  behind  forward,  as  to  be  immovable, 
and  by  reason  of  this  immobility  of  the  rectum,  the  former  plan  of 
operation  had  to  be  abandoned. 

Fortunately,  it  was  possible  to  dislodge  the  body  from  this  fixed  posi- 
tion, and  M.  Lucas  Championniere,  who,  at  that  moment,  practised  the 
rectal  touch,  received  it  upon  the  end  of  his  finger.  While  an  assistant 
fixed  the  body  by  pressing  on  the  abdomen,  M.  Verneuil  endeavored  to 
seize  it  with  the  forceps  of  Muzeux,  or  to  fix  it  with  a  gimlet,  but  with- 
out success.  Linear  proctotomy  was  then  resorted  to,  and  M.  Verneuil 
succeeded  in  moving  the  body  with  one  of  the  blades  of  a  lithotomy 
forceps,  bringing  it  down,  and  seizing  it  with  another  pair  of  strong 
forceps.  The  instrument  slipped  many  times  on  the  bark  of  the  wild 
cherry  wood,  and  it  was  only  after  many  long  and  painful  attempts' 
practised  with  a  very  defective  stock  of  tools,  that  the  foreign  body  was 
finally  withdrawn.  It  was  followed  by  a  discharge  of  very  foetid  faecal 
matter  and  a  little  blood.  The  result  of  the  operation,  thanks  to  the 
precautions  taken  during  the  manoeuvres  and  the  treatment  subsequently 
employed,  surpassed  all  expectations.  The  abdominal  wound  healed  by 
first  intention  under  Lister's  dressing,  and  a  soft-rubber  catheter,  kept 
permanently  in  the  rectum,  through  which  chloral  was  injected  every 
two  hours,  prevented  any  complications  in  that  part. 

These  four  cases  indicate  with  sufficient  clearness  the  general  rules 
which  should  guide  the  practitioner.  The  operation  is  applicable  only 
to  bodies  high  up  in  the  rectum.  The  point  of  incision  may  be  in  the 
median  line,  over  the  sigmoid  flexure  in  the  left  loin,  or  over  what  seems 
to  be  the  most  prominent  point  of  the  foreign  body,  wherever  that  may  be. 
If  the  intestine  is  healthy,  it  may  be  closed  and  returned  into  the  body.  If 
not,  an  artificial  anus  should  be  made  at  the  point  of  incision. 

It  is  worthy  of  note  that  all  of  the  cases  thus  far  recorded  have  ended 
in  recovery. 


PKUB1TU8    ANI.  269 


CHAPTER    XIII. 

PRURITUS   ANI. 

Pruritus  generally  a  Symptom  of  some  other  Disease. — Description. — Causes. — 
Relation  of  Internal  Haemorrhoids,  Fistula,  Worms,  Parasites,  and  Eczema  to 
Pruritus. — Treatment  of  Eczema. — Herpes  and  Erythema. — Ck)nstitutional 
Conditions  causing  Pruritus. — Dependence  upon  Constipation. — Treatment 
of  Constipation. — General  Treatment  of  Pruritus. 

Pruritus  ani — itching  at  the  anus — is  generally  a  symptom  of  some 
other  disease  such  as  haemoiThoids  or  eczema,  but  it  is  often  present  in  a 
marked  degree  when  no  cause  for  its  existence  can  be  discovered.  It  is 
an  exceedingly  painful  and  annoying  affection,  and  one  which  will  often 
tax  the  powers  of  the  surgeon  to  the  utmost  for  its  cure.  It  is  met  with 
in  both  men  and  women  and  seems  to  be  dependent  upon  no  particular 
general  state,  being  found  in  rich  and  poor,  tlie  overfed  and  underfed, 
the  professional  man  of  nervous  constitution  and  the  laborer,  alike. 

The  disease  is  marked  by  an  itching  at  the  anus  which  is  more  or  less 
constant,  but  is  generally  worse  after  the  sufferer  has  become  warm  in 
bed  at  night.  The  itching  causes  an  attempt  at  relief  by  scratching,  and 
the  scratching,  though  it  may  be  controlled  during  the  day,  is  generally 
practised  unconsciously  during  sleep  to  an  extent  which  causes  laceration 
of  the  skin.  The  itching  in  bad  cases,  even  when  constant,  is  marked  by 
exacerbations  and  remissions,  and  may  cause  an  amount  of  suffering 
which  is  simply  unbearable. 

The  disease  is  attended  by  certain  changes  in  the  appearance  of  the 
parts.  The  skin  becomes  thickened  and  parchment-like  or  else  eczema- 
tous  and  moist  from  exudation.  It  may  be  red  from  the  scratching,  or 
there  may  be  quite  a  characteristic  loss  of  the  natural  pigment  of  the  anus. 
In  the  latter  case  the  skin  becomes  of  a  dull-whitish  color,  and  this  will 
oftened  be  noticed  where  the  disease  is  of  long  standing  and  severe.  The 
exudation  may  be  very  marked  where  the  itching  is  slight,  and  may  be 
attributed  by  tlie  patient  to  trouble  within  the  rectum  instead  of  to  its 
real  source. 

Catcses. — The  cause  of  pruritus  may  sometimes  be  easily  discoverable 
and  in  such  cases  a  cure  rapidly  follows  its  removal.  For  example,  pruri- 
tus is  often  a  symptom  of  internal  haemorrhoids  and  is  easily  and  effect- 


270  DISEASES    OF    THE    KECTUM    AND    ANUS. 

ually  cured  by  their  removal.  Again  it  is  often  a  symptom  or  complica- 
tion of  a  fistula  with  a  small  external  opening  such  as  may  easily  be 
overlooked  in  a  cursory  examination;  and  is  cured  by  the  ordinary  opera- 
tion and  the  consequent  cessation  of  the  discharge  upon  which  it  depends. 
It  is  often  dependent  upon  the  presence  of  the  oxyuris  vermiciilaris  in 
the  rectum  and  in  every  case  these  should  be  carefully  looked  for.  If 
they  are  present  they  may  generally  be  seen  like  small  pieces  of  white 
thread  between  the  radiating  folds  at  the  margin  of  the  anus,  especially  at 
night  when  the  itching  begins.  They  may  generally  be  eradicated  by 
certain  simple  measures,  the  best  known  of  which  is  an  enema  of  lime- 
water,  or  of  carbolic  acid,  3  i. ;  glycerin,  §  i.;  and  water,  3  vij.,  injected 
after  each  passage.  Turjientine  and  tincture  of  iron  may  be  used  for 
the  same  purj)ose  and  are  both  very  effectual;  but  the  parasites  are  much 
more  easily  removed  in  children  than  in  adults,  and  I  have  had  one  case 
which  was  exceedingly  intractable,  and  in  which  I  have  never  been  able 
to  keep  the  worms  from  returning  for  any  great  length  of  time.  A  single 
examination  should  never  be  considered  as  proof  of  the  absence  of  this 
parasite  in  an  obstinate  case  of  pruritus. 

Instead  of  a  parasite  located  within  the  rectum,  pruritus  is  occasion- 
ally easily  accounted  for  by  the  presence  of  pediculi.  In  such  a  case  the 
diagnosis  and  cure  are  alike  easy. 

Again  the  parasite  may  be  vegetable  instead  of  animal,  and  the  itch- 
ing may  be  due  to  the  disease  known  as  eczema  marginatum.  In  this  case 
the  diagnosis  will  rest  upon  the  finding  of  the  spores  under  the  micro- 
scope in  the  epidermis  scraped  from  the  edge  of  the  affected  spot  and 
moistened  with  glycerin.  The  most  effectual  remedy  for  this  condition 
is  a  wash  of  equal  parts  of  sulphurous  add  and  water  frequently  applied 
with  a  soft  cloth,  and  gradually  increased  in  strength,  if  necessary,  up  to 
the  pure  acid,  which  latter  is,  however,  generally  a  painful  application. 
Strong  tincture  of  iodine  applied  with  a  brush  is  also  an  effectual  remedy 
in  eradicating  the  plant. 

Pruritus  may  also  be  dependent  upon  other  skin  diseases,  among  which 
chronic  eczema  is  perhaps  the  most  common,  and  this  is  to  be  treated 
exactly  here  as  elsewhere  in  the  body,  first  by  general  measures  directed 
to  the  constitutional  state,  and  second,  by  local  applications.  The  conges- 
tion and  the  thickening  of  the  skin  must  first  be  remedied,  and  for  this 
purpose  very  hot  water,  compound  tincture  of  green  soap,  and  if  necesary 
a  solution  of  caustic  potash  may  be  applied.  The  water,  to  be  of  any  use, 
must  be  as  hot  as  the  fingers  can  bear,  and  should  be  applied  to  the  part 
with  a  soft  cloth  and  held  there  till  it  begins  to  cool.  This  may  be  re- 
peated half  a  dozen  times,  but  all  rubbing  should  be  carefully  avoided 
both  during  the  application  and  in  drying  the  parts  after  it.  This  is  a 
favorite  remedy  with  most  dermatologists;  it  should  be  used  just  before 
going  to  bed,  and  is  often  in  itself  sufl&cient  to  insure  a  good  night's 
sleep. 


PEUBITU8    AMI.  271 

If  there  be  thickening  of  the  skin  from  effusion,  a  stronger  application 
than  hot  water  will  be  necessary;  and  for  this  the  compound  tincture  of 
green  soap  is  a  good  remedy;  or  the  solution  of  potash  (gr.  v.-  f  i.)  or 
liquor  potassae  may  be  resorted  to  with  caution.  The  formula  for  the 
compound  tincture  of  green  soap  is  the  following: 

IJ  Saponis  viridis, 

Olei  cadini, 

Alcohol M  f  i. 

M. 

It  is  a  much  stronger  preparation  than  the  simple  green  soap  and  also 
a  much  more  disagreeable  one,  but  it  is  very  effectual  and  should  be  well 
rubbed  into  the  part  once  a  day.  These  remedies  should  be  followed  at. 
once  by  soothing  ointments,  or  lotions,  A  good  ointment  is  the  ordinar 
oxide  of  zinc  made  soft  and  applied  gently,  and  one  which  is  pretty  cer- 
tain to  allay  itching  is  that  made  of  chloroform  (  3  i.-  3  i.).  This  soon 
loses  its  power  by  the  evaporation  of  the  chloroform  and  should  on  this 
account  be  kept  in  a  wide-mouthed  glass  bottle,  tightly  corked,  and 
should  be  frequently  renewed.  Another  favorite  application,  and  one 
which  is  very  generally  effectual,  consists  in  a  lotion  of  carbolic  acid. 
The  formula  is: 

3  Acid,  carbolici 3  ss. 

Glycerinae §  i. 

Aquae |  ii j. 

This  may  be  applied  at  night,  and  if  found  to  be  too  strong  may  be 
diluted  by  the  j)atient.  In  a  more  dilute  form  it  may  also  be  continued 
ior  a  considerable  time  after  all  symptoms  have  ceased. 

For  the  sake  of  those  who  have  never  encountered  an  obstinate  case 
of  this  disease,  but  who  are  pretty  sure  at  some  time  to  have  both  knowl- 
edge and  ingenuity  taxed  to  the  utmost,  I  will  give  one  or  two  more  for- 
mulae which  have  been  found  reliable.  The  following  comes  from  Ailing- 
ham,  and  by  it  alone  he  has  ''seen  a  bad  case  cured  in  forty-eight 
hours." 

Q  Liquoris  carbonis  detergens  (Wright's), 

Glycerinae &&  5  i. 

Pulv.  zinci  oxidi, 

Calamin.  prep aa  3  ss. 

Pulv.  sulph.  precip 3  ss. 

Aquae  purae ad  f  vi. 

The  part  affected  is  to  be  thickly  painted  over  with  this  once  or  twice 
a  day  and  allowed  to  dry.  The  white  precipitate  ointment  made  soft  with 
vaseline  or  glycerin  is  also  a  good  application,  and  the  following  lotion, 
also  from  AUingham,  will  often  work  well  in  allaying  irritation: 


272  DISEASES    OF    THE   KECfUM   AND    ANUS. 

1},  Sodae  biboratis 3  ij. 

Morpli.  hydrochlor gr.  xvi. 

Acidi  hydrocyanic,  dil 3  ss. 

Glycerinae §  ij. 

Aquae ad  ?  viij. 

M. 

This  should  be  applied  to  the  part  four  or  five  times  in  the  twenty- 
four  hours.  Dr.  Bulkley'  has  also  recommended  the  following  as  being 
useful,  and  I  have  often  found  it  so. 

^  Ungt.  picis 3  iij. 

"      bellad 3  ij. 

Tr .  aconit.  rad 3  ss. 

Zinci  oxidi 3  i. 

Ungt.  aquae  ros 3  iij. 

M. 

An  ointment  of  chloral  and  camphor,  a  drachm  of  each  to  the  ounce, 
is  also  at  times  effectual  in  allaying  itching. 

There  are  two  other  skin  diseases  either  of  which  may  be  the  cause  of 
pruritus — herpes  and  erythema.  Herpes  at  the  margin  of  the  anus  is  the 
same  as  when  seen  on  the  lips.  In  the  latter  case  it  heals  spontaneously, 
in  the  former  a  dressing  may  be  necessary.  This  may  consist  simply  of 
a  dry  powder  such  as  zinc  or  bismuth,  or  of  one  of  the  lotions  already 
mentioned.  Erythema  will  be  found  chiefly  in  fat  people  where  it  is 
due  to  contact  of  the  opposing  cutaneous  surfaces.  It  also  is  best  treated 
by  the  application  of  dry  powders,  and  by  separating  the  opposed  sur- 
faces by  a  layer  of  dry  sheet  lint  or  old  muslin. 

These  are  the  most  palpable  and  perhaps  also  the  most  common 
causes  of  pruritus,  but  there  are  many  cases  in  which  the  cause  is  not  so 
easily  discoverable,  because  it  is  a  constitutional  and  not  a  local  one. 
Where  no  local  cause  can  be  detected,  a  careful  inquiry  must  be  instituted 
with  regard  to  the  patient's  general  health  and  habits.  If  chronic  con- 
stipation be  present,  this  must  first  of  all  be  overcome,  for  this  is  in  itself 
an  efficient  cause  for  the  disease.  The  treatment  of  chronic  constipation 
is  by  no  means  a  simple  matter.  It  may  be  begun  with  a  purgative  such 
as  three  compound  cathartic  pills,  for  the  sake  of  opening  the  way  for 
future  treatment,  but  here  the  administration  of  purgatives  should  end, 
for  their  repeated  administration  is  calculated  to  do  harm  rather  than 
good,  by  substituting  an  occasional  over-action  for  the  daily  one  which 
indicates  a  healthy  state  of  the  intestinal  tract.  The  following  sugges- 
tions may  be  found  of  use  in  the  treatment  of  this  condition  which  is  one 
that  must  be  overcome  at  the  commencement  of  the  treatment  of  any 
rectal  affections  with  which  it  may  be  associated. 

Constipation  may  be  due  to  deficient  action  of  either  the  small  or  the 
large  intestine,  and  this  deficient  action  in  either  case  may  be  the  result 
either  of  deficient  secretion  or  deficient  nerve  power. 

1  The  Med.  Record,  December  18th,  1880. 


PRURITUS    ANI.  278 

Deficient  secretion  is  very  apt  to  be  associated  with  hepatic  disturb- 
ance, and  is  marked  by  dull  headache,  bad  taste  in  the  mouth,  viscid 
secretion  from  the  buccal  glands,  etc.  This  is  a  condition  pretty  sure  to 
be  aggravated  by  cathartics,  for  the  reason  that  the  temporary  increase  in 
secretion  which  they  cause  is  followed  by  a  corresponding  decrease,  which 
serves  only  to  make  the  patient  worse  than  before.  For  the  purpose  of 
increasing  the  natural  secretion  of  the  small  intestine,  the  fruits  contain- 
ing citric  acid,  such  as  oranges;  and  other  fruits,  such  as  figs  and  apples, 
when  the  patient  can  digest  them,  all  serve  a  good  purpose.  Water  is 
also  an  excellent  remedy,  and  two  tuniblcrfuls  of  it  taken  in  the  mornmg 
will  often  be  very  beneficial.  To  it  may  be  added  a  slight  saline,  which 
decreases  its  capability  for  absorption  (  3  ss.-0.i.),  and,  therefore,  increases 
the  peristalsis;  and  the  addition  of  a  single  grain  of  quinine  is  said  to 
greatly  increase  the  effect.'  This  treatment,  if  patiently  persisted  in  for 
a  few  weeks,  will  generally  be  followed  by  a  good  result 

Deficient  innervation  will  be  found  in  most  cases  of  constipation  in 
old  people,  people  of  sedentary  habits,  and  those  who  have  little  exercise. 
It  is  generally  attended  by  deficient  action  of  the  skin  and  a  sallow  com- 
plexion. In  such  cases  water  will  be  found  only  to  weaken  the  digestive 
power,  unless  it  can  be  combined  with  a  different  mode  of  life  and 
abundance  of  out-door  exercise.  Cold  bathing,  however,  cold  against 
the  spine  and  abdomen,  plenty  of  exercise  in  the  open  air,  and  nux  vom- 
ica will  generally  be  found  to  give  relief. 

In  constipation  dependent  upon  the  large  intestine,  the  trouble  will 
generally  be  found  to  be  due  to  deficient  innervation  rather  than  to  any 
liick  in  the  secretion.  It  is  best  treated  by  keeping  the  rectum  empty, 
by  nux  vomica,  or  belladonna  in  doses  sufficient  to  cause  dryness  of  the 
throat,  and  by  electricity.  The  latter  should  be  in  the  form  of  the  Fa- 
rad ic  current,  one  pole  being  placed  over  the  spine  and  the  other  passed 
up  and  down  along  the  track  of  the  colon. 

Infantile  constipation  may  be  due,  as  pointed  out  by  Jacobi,  to  the 
disproportionate  length  of  the  sigmoid  flexure.  In  children  it  is  not  un- 
usual to  find  two,  or  even  three,  flexures  in  the  lower  part  of  the  colon, 
in  which  the  faces  may  remain  until  they  become  hard  and  friable,  and 
when  such  an  anatomical  formation  is  associated  with  a  deficiency  of  the 
intestinal  secretion,  a  very  obstinate  constipation,  and  even  impaction, 
may  result.  In  such  a  case  out-meal  is  to  be  given  in  preference  to  tiipi- 
oca,  rice,  or  barley,  and  with  it  an  abundance  of  water.  Purgatives 
should  never  be  administered  except  in  extreme  cases,  enemata  being  pre- 
ferable.'    Fa?cal  accumulation  is  not  very  uncommon  in  young  children. 

In  chronic  constipation,  the  patient  should  first  of  all  be  instructed 
to  have  a  regular  time  for  the  daily  evacuation,  and  the  best  time  for  this 
purpose  is  immediately  after  breakfast.     The  time  being  fixed,  the  patient 

'  Tliompson,  New  York  Me<l.  Record,  May  5th,  1877. 
'  N.  Y.  Med.  Record,  Sept.  25th,  1880. 

IS 


274  DISEASES    OF   THE    RECTUM    AND    ANUS. 

is  to  go  to  the  closet  whether  the  desire  for  a  passage  be  present  or  not, 
and  pass  a  certain  time  upon  the  commode.  I  generally  recommend  the 
time  immediately  after  the  morniug  meal  for  this  purpose,  because  the 
breakfast  itself  often  acts  a  stimulant  to  this  function,  especially  in  those 
in  the  habit  of  taking  a  morning  cup  of  coffee.  If  the  patient  be  a  man 
in  the  habit  of  smoking,  the  first  few  whiffs  of  smoke  often  act  in  the 
same  way;  and  there  are  many  men  to  whom  the  morning  cigar  or  cigar, 
ette  is  an  essential  to  the  daily  evacuation.  In  such  a  case  it  must  be  a 
very  decided  ojiponent  of  the  weed  who  would  object  to  its  continuance 
in  moderation. 

If  the  plain  cold  water  taken  in  the  morning  has  no  effect,  the  min- 
eral waters  may  be  tried  in  its  place  with  great  advantage;  and  the  patient 
may  select  the  one  most  agreeable  to  the  taste  and  which  most  effectually 
accomplishes  the  desired  end.  The  morning  meal  may  consist  of  what- 
ever the  patient  most  desires,  but  a  dish  of  oat-meal  or  coarse  cracked 
wheat  and  milk  should  always  be  an  essential  part  of  it. 

A  laxative  bread  may  be  made  of  equal  parts  of  coarse  Scotch  oat-, 
meal,  whole  wheaten  flour,  and  coarse  ordinary  flour,  with  yeast  or  baking 
power.     This  may  be  eaten  once  or  twice  daily. ' 

I  have  almost  always  found  that  where  perfect  regularity  in  the  daily 
life  with  regard  to  eating  and  exercise  can  be  established,  the  function 
of  defecation  will  also  be  performed  regularly,  provided  the  diet  be  plain 
and  rather  coarse  in  quality.  To  have  a  copious,  well-formed  evacuation 
it  is  necessary  first  of  all  that  the  diet  should  be  composed  of  substances 
which  leave  a  considerable  quantity  of  waste,  and  chief  among  these  are 
the  coarser  grains  and  the  vegetables.  In  women  a  certain  regulated 
amount  of  daily  out-door  exercise  should  be  insisted  upon,  in  spite  of  all 
excuses  and  professions  of  disability,  if  necessary,  this  may  be  small  at 
first,  and  gradually  increased;  and  in  a  woman  who  has  lost  the  habit, 
and,  perhaps,  almost  the  power  of  walking,  considerable  tact  and  firm- 
ness on  the  part  of  the  physician  may  be  required  to  carry  out  this  part 
of  the  treatment,  but  it  will  be  found  to  be  care  well  spent. 

In  addition  to  these  dietetic  and  hygienic  rules,  certain  medication 
may  and  often  will  be  found  necessary.  This  should  be  of  the  mildest 
possible  kind  which  will  accomplish  the  object.  A  pill  which  I  have 
found  to  act  very  effectually  and  pleasantly  under  these  circumstances  is 
made  after  the  following  formula  : 

^  Pulv.  aloes  soc gr.  iss. 

Ext.  nucis  vom gr.  ss. 

Ext.  belladonnse S^-  h 

M. 

One  of  these  should  be  taken  at  bed-time,  and  will  generally  be  fol- 
lowed by  an  easy  passage  on  the  following  morning.  If  this  does  not 
work  satisfactorily,  various  other  remedies  may  be  substituted,  amongst 

'  W.  H.  Taylor,  Lancet,  May  31st,  1879. 


PRURITUS    ANI.  275 

the  best  of  wliich  is  the  compound  licorice  powder,  the  rhubarb  and  soda 
mixture,  or  the  dinner  pill;  the  object  being  to  find  one  among  the  many 
laxative  preparations  which,  without  causing  pain  or  diarrhcBa,  will  give 
an  easy  and  natural  evacuation  of  the  bowels  once  every  day. 

The  use  of  enemata  for  chronic  constipation  should  not  be  commenced 
till  all  other  means  have  failed,  for  the  reason  that  when  once  the  bowel  has 
become  accustomed  to  this  form  of  stimulus  it  will  be  found  very  difficult 
to  discontinue  its  use.  In  some  cases,  however,  their  employment  may 
be  a  necessity  and  they  are  always  much  less  harmful  than  purgatives. 
Instead  of  tlie  ordinary  enema  of  soap  and  water,  the  introduction  of  a 
harmless  foreign  body  into  the  rectum  will  sometimes  excite  peristalsis. 
Small  fragments  of  soap  or  of  candles  ai'e  preferred  by  many  for  this  pur- 
pose to  fluid  injections. 

In  ciui ?3  where  enemata  have  lost  their  power  from  prolonged  use  my 
own  practice  is  to  resort  to  the  use  of  a  long  rectal  tube  two  or  three 
times  a  week;  but  this  should  not  be  trusted  to  the  patient  for  fear  of 
accidents.  Most  patients  will  find  it  impossible  to  introduce  them  easily 
and  will  not  care  to  make  the  attempt.  With  a  long  flexible  tube  of 
small  calibre  a  pint  or  more  of  water  may  easily  be  thrown  into  the  sigmoid 
flexure  and  colon  and  the  bowel  be  thoroughly  emptied. 

Another  not  infrequent  cause  of  pruritus  is  derangement  in  the  func- 
tion of  the  liver.  This  may  or  may  not  be  associated  with  the  constipa- 
tion which  we  have  just  considered.  It  must  be  treated  by  general 
dietetic  measures,  the  dilute  mineral  acids,  occasionally  by  doses  of  podo- 
phyllin,  active  out-of-door  exercise,  and  cold  and  friction  applied  to  the 
hepatic  region.  In  women  uterine  disorders  must  be  looked  for  and 
cured  before  very  much  will  be  accomplished  in  the  treatment  of  pruritus; 
and  in  women  also  the  urine  must  be  examined  for  sugar  in  obstinate 
cases,  for  diabetes  will  sometimes  give  rise  to  incurable  pruritus. 

In  case  none  of  tliese  causes  can  be  found  to  account  for  tlie  itching, 
errors  of  diet  must  be  searched  for,  and  corrected  when  found.  Any- 
thing like  excess  in  smoking  or  in  alcoholic  drinks  will  keep  up  the 
disease,  and  in  men  these  habits  must  be  carefully  regulated  if 
indulged  in  at  all.  The  di:?ease  will  sometimes  be  encountered  in  stout 
full-blooded  persons  who  live  well  and  perhaps  incline  to  the  gout,  and 
who  show  no  other  signs  of  disorder.  In  such,  active  exercise  and  plainer 
living  with  cold  l)uthing  of  the  part  at  nigiit  and  morning  and  tlie  use  of 
a  lotion  of  carbolic  acid  will  often  effect  a  speedy  cure.  On  the  other 
hand,  the  disease  may  be  present  in  exactly  the  opposite  class  of  persons, 
the  overworked  and  worried  professional  or  business  man,  and  it  is  in  this 
class  of  cases  alone  where  the  itching  seems  to  1x5  purely  a  nervous  symp- 
tom that  arsenic  is  indicated.  It  may  Ijo  combined  with  quinine  and 
cod-liver  oil  and  carried  up  to  its  full  physiological  effect.  As  a  relief 
for  the  intolerable  itchings  at  night,  Allingham  recommends  the  intro- 
duction of  "  a  bone  plug  shaped  like  the  nipple  of  an  infant's  feeding 


276  DISEASES    OF   THE    RECTUM    AND    ANUS. 

bottle,  and  with  a  circular  shield  to  prevent  its  slipping  into  the  bowel." 
Its  benefit  is  explained  by  the  pressure  it  exerts  upon  the  terminal  fila- 
ments of  the  blood-vessels  and  nerves  of  the  anus. 

In  this  way  then  the  physician  must  undertake  the  cure  of  a  case  of 
pruritus  ani;  and  not  by  the  administration  of  any  single  lotion  or  oint- 
ment to  allay  the  itching  which  is  but  the  symptom  of  some  local  or 
general  condition.  In  every  case  the  cause  must  be  found  and  removed 
if  success  in  the  treatment  is  to  be  gained.  I  know  of  no  disease  of  the 
rectum  or  anus  in  which  there  is  a  better  chance  for  the  practitioner  to 
show  his  general  knowledge  and  skill.  If  a  case  be  undertaken  in  this 
way,  and  the  treatment  be  intelligently  followed  by  both  doctor  and 
patient,  a  cure  may  generally  be  effected;  sometimes  in  a  very  few  days, 
but  at  others  only  after  prolonged  effort  and  many  discouragements. 
The  prognosis  should,  therefore,  be  guarded  at  the  outset  lest  the  patient 
be  led  to  expect  a  too  speedy  relief,  and  in  some  cases,  in  spite  of  the  best 
of  care,  the  disease  will  frequently  return  and  the  patient  can  scarcely  at 
any  time  consider  himself  as  perfectly  cured. 


8FABK    OK    THE   SPUINCTEJEt.  277 


CHAPTER  XIV. 

SPASM   OF  THE  SPHTN'CTER. — NEURALGIA. — WOUNDS. — RECTAL    ALIMEN- 
TATION. 

Spasm  Without  Other  Disease. — Cases. — Authorities. — Symptoms. — ^Treatment. 
— Neuralgia. — Cases. — Diagnosis. — Treatment. — ^Wounds. — Complications  — 
Spontaneous  Rupture. — ^Treatment  of  Wounds. — Alimentation. — Physiology 
of  Absorption. — Nutritive  Enemata. — Nutritive  Suppositories. 

Spasm  of  the  sphincter  without  the  presence  of  any  other  rectal  affec- 
tion is  undoubtedly  rare.  Ita  general  character  may  perhaps  best  be 
shown  by  the  citation  of  the  following  cases. 

Case  XXVIII. — Physician,  aged  twenty-eight.  The  patient  was  a 
man  decidedly  given  to  thinking  about  his  own  health,  and  though 
generally  well,  not  at  all  robust.  He  came  to  me  complaining  of  a  sense 
of  discomfort  about  the  rectum,  accompanied  by  difficulty  in  defecation. 
The  discomfort  seldom  amounted  to  actual  pain,  and  he  had  noticed  that 
when  he  was  away  on  his  summer  vacations  he  was  always  better  and  in 
fact  perfectly  well.  Nevertheless,  the  trouble  in  defecation  had  increased 
so  markedly  during  the  past  few  months  that  he  was  fully  convinced  that 
he  was  suffering  from  actual  stricture. 

An  attempt  at  digital  examination  caused  the  most  exquisite  suffering, 
forcing  the  patient  to  cry  out  in  agony,  and  yet  there  was  entire  absence 
of  any  lesion. 

The  treatment  was  based  upon  the  fact  which  he  had  himself  noted, 
that  when  his  general  condition  was  improved  the  local  trouble  ceased; 
and  the  patient  was  cured  by  i)urely  general  measures  looking  toward 
the  building  up  of  the  system. 

Case  XXIX. — Professional  man.     Age,  thirty. 

In  this  case  also  the  only  symptom  complained  of  was  pain  on  defeca- 
tion, sometimes  severe,  sometimes  slight.  The  history  given  pointed  so 
strongly  toward  the  existence  of  a  fissure  that  I  etherized  the  patient, 
fully  expecting  to  cure  him  by'  stretching  the  sphincter.  He  was 
entirely  cured  by  stretching  the  muscle,  but,  to  my  surprise,  a  most  care- 
ful examination  revealed  no  disease;  and,  being  dubious  myself  about  the 
existence  of  spasm  without  fissure,  the  examination  was  a  very  thorough 


278  DISEASES    OF   THE    BECJTUil    AND    AKU8. 

one.  This  patient  was  also  a  man  of  sedentary  habits  and  of  rather  a 
nervoits  character. 

The  following  case  is  taken  from  Syme,  and  is  characterized  by  him  as 
a  remarkable  instance  of  the  affection.'  "I  was  asked  to  see  a  gentle- 
man, about  sixty  years  of  age,  who  stated  that,  a  few  weeks  before,  after 
sitting  out  a  long  debate  in  the  House  of  Commons,  he  had  felt  extreme 
difficulty  in  evacuating  the  bowels,  having  previously  for  several  years 
experienced  more  or  less  uneasiness  from  this  source;  that  he  had  con- 
sulted a  physician  and  surgeon  in  London,  who  prescribed  laxatives 
without  affording  relief;  and  that  his  complaint  had  continued  so  as  at 
length  to  confine  him  to  bed.  I  proposed  an  enema,  which  was  at  once 
objected  to  on  the  ground  that  the  anus  would  not  admit  tlie  smallest- 
sized  tube.  Suspicion  being  thus  excited,  the  anus  was  examined  and 
found  to  present  the  characteristic  features  of  spasmodic  stricture. 
Having  explained  my  views  of  the  case,  I  gently  insinuated  the  narrow 
sheath  of  a  histoury  cache,  which  I  happened  to  have  with  me,  and  then 
expanding  the  blade,  withdrew  it,  so  as  to  make  an  incision  on  one  side 
of  the  orifice.  A  copious  stool  immediately  followed,  and  the  patient 
was  at  once  completely  relieved  from  his  complaint." 

With  regard  to  this  mucli  disputed  affection,  a  citation  of  authorities 
may  be  useful.  Syme '  believed  that  spasm  existed  as  an  independent 
condition  without  morbid  change;  that,  though  there  could  be  no  doubt 
that  spasm  and  fissure  frequently  existed  together,  it  was  not  reconcilable 
with  the  facts  met  with  in  practice  that  spasmodic  stricture  was  always 
of  secondary  origin  and  dependent  upon  the  fissure.  He  says:  "In  a 
considerable  number  of  cases,  I  have  found  the  sphincter  firmly  con- 
tracted without  any  perceptible  fissure  or  abrasion  of  the  surface." 

Mayo  describes  spasm  of  the  sphincter  as  a  kind  of  cramp  which  often 
comes  on  suddenly,  sometimes  at  night  during  sleep.  The  paroxysms 
may  occur  daily  or  two  or  three  times  a  year;  and  the  attack  may  come 
gradually  and  cause  uneasiness  for  two  or  three  days,  and  then  pass  away, 
or  its  coming  and  going  maybe  sudden.  He  says:  *' There  are  cases  in 
which  the  disease  produces  long-continued  and  permanent  suffering;  in 
which  the  anus  becomes  permanently  contracted  and  hardened,  consti- 
tuting, therefore,  a  permanent  stricture,  and  generally  combining  both 
permanent  and  spasmodic  contraction.  The  motions  are  passed  with  an 
effort  and  with  pain,  and  all  the  common  symptoms  of  stricture  of  the 
rectum  are  present. 

Allingham'  says:  "Spasm  of  the  sphincter  has  been  said  to  be  the 
cause  of  impaction,  but  I  have  more  often  thought  the  reverse  was  the 
case;  and  the  impaction   the  cause   of  the   spasm.     I  must,  however, 

'  Diseases  of  the  Rectum.     Edinburgh,  1838,  p.  138. 
«  Loc.  cit.,  p.  134. 
8  Op.  cit.,  p.  210. 


8PASM   OF   THE    SPHINCTER.  279 

acknowle<\ge  that  spasm  is  often  tlie  cause  of  the  constipation  which  is 
the  forerunner  of  impaction.  In  impaction,  spasm  of  tlie  sphincter 
always  exists;  in  some  instances  to  such  a  degree  that,  when  the  patient 
strained,  I  have  observed  the  anus  protruded  like  a  nipple,  and  an  injec- 
tion returned  in  a  fine  stream  as  if  coming  out  of  a  squirt.  I  have  cer- 
tainly met  with  cases  of  idiopathic  spasm  of  the  sphincter  usually  in 
elderly,  nervous,  single  women,  and  though  no  impaction  was  present, 
costiveness  was." 

Quain'  concludes  that  "where  pain,  brought  on  by  faecal  evacuations 
and  continuing  after  them,  happens  to  be  present,  the  fault — the  morbid 
condition — is  not  in  the  sphincter,  but  in  the  skin  or  mucous  membrane 
covering  it,  and  that  the  division  of  the  muscle  is  not  required  in  order 
to  remove  the  patient's  suffering."  In  other  words,  that  spasm  is  jdways 
depeixdent  upon  fissure.  Boyer*  treats  of  ** constriction  with  fissure" 
and  *•' constriction  without  fissure." 

Dupuytren*  says:  "The  gravity  of  this  affection  (fissure)  depends 
chiefly  on  the  painful  spasm  of  the  sphincters;  the  fissure  is  only  an  acci- 
dent, as  is  proved  bv  the  existence  of  painful  spasm  without  fissure, 
which,  according  to  well-known  surgical  authorities,  is  found  in  propor- 
tion to  the  other  of  one  to  four."  And,  **the  spasmodic  constriction  is 
the  true  lesion,  and  the  fissure  only  an  epiphenomenon."  Sir  B.  Brodie* 
held  the  same  views. 

The  symptoms  of  spasm  of  the  sphincter  are  pain  on  defecation  and 
for  a  time  after;  more  or  less  uneasiness  about  the  anus,  especially  when 
sitting;  fulness  in  the  perineum;  often  more  or  less  trouble  with  the 
bladder,  as  shown  by  frequent  micturition,  sometimes  attended  by  smart- 
ing in  the  uretlira  and  constipation.  The  disease  is  generally  attended 
by  exacerbations  and  remissions.  A  digital  examination  of  the  anus  is 
always  painful,  and  the  contraction  may  be  so  great  as  to  leave  hardly  a 
trace  of  the  anal  orifice.  Any  anxiety  or  distress  of  mind,  a  generally 
irritable  nervous  condition,  and  everything  which  has  a  tendency  to  irri- 
tate the  rectum,  or  the  parts  around,  will  aggravate  the  complaint.  It 
may  easily  be  confounded  with  the  affection  next  to  be  described,  neur- 
algia, but  is  generally  distinguishable  from  it  by  the  marked  dependence 
of  the  pain  upon  the  act  of  defecation,  which  is  not  seen  in  neuralgia 
without  spasm. 

Tlie  treatment  consists  in  attention  to  the  general  health  of  the  pa- 
tient, in  allaying  any  nervous  extitement,  in  the  administration  of  a 
cathai'tic  to  empty  the  bowel  Vhen  the  s])asm  is  present;  and  in  ano- 
dyne injections,  such  as,  for  example,  of  twenty  drops  of  laudanum  in 


'  The  Diseases  of  the  Rectum.    London,  1854,  p.  167. 

'  Traite  des  Maladies  Chirurg.,  etc.,  fourth  edition,  t.  x.,  p.  189. 

'  Lemons  orales  de  Clinique  Cliirurg.,  t.  iii.,  p.  284. 

■*  Lectures  on  Diseases  of  the  Rectum.     London  Med.  Gaz.,  voL  xri.,  p.  26. 


280  DISEASES   OF   THE    EECTUM   AND    ANUS. 

an  ounce  of  water.  Suppositories  may  cause  renewed  irritation.  Even 
in  the  more  aggravated  form,  the  disease  will  often  yield  to  such  mea- 
sures as  this,  but,  if  it  does  not,  a  cure  may  always  be  effected  by  forci- 
ble dilatation  of  the  sphincter  under  ether.  If  the  patient  will  not 
submit  to  this,  the  next  best  thing  will  be  found  to  be  the  introduction 
and  retention  of  a  bougie. 

Neuralgia. — Neuralgia  of  the  rectum  is  generally  met  with  in  nerv- 
ous people,  especially  females,  such  as  are  subject  to  neuralgia  in  other 
parts  of  the  body.     The  following  cases  show  its  general  character. 

Case  XXX. — Professional  man,  age  49.  The  patient  was  slight  and 
pale  from  sedentary  habits,  but  was  generally  well.  Thirteen  months 
before  consulting  me  he  was  operated  upon  for  fissure,  and  after  the 
operation  he  had  for  some  time  been  entirely  well,  but  he  now  has  Avhat 
he  describes  as  a  dull,  wearing  pain  in  the  rectum,  coming  on  while  at 
his  daily  work,  lasting  a  longer  or  shorter  time,  sometimes  all  day,  but 
generally  passing  away  after  he  has  reached  his  home  and  become  quiet 
and  rested.  He  has  noticed  that  the  pain  has  a  direct  connection 
with  the  state  of  his  general  health,  and  that,  when  he  is  away  from  his 
work  and  rusticating,  he  is  entirely  free  from  it.  The  pain  is  no  greater 
at  the  time  of  defecation  than  at  any  other,  and  is  never  so  severe  as  to 
be  unbearable.  A  careful  examination  of  the  part  failed  entirely  to  show 
any  lesion. 

Case  XXXI. — Woman,  aged  65,  married.  This  patient  had  been 
treated  for  fissure,  for  ulceration,  and  for  coccygodynia,  and  had  refused 
to  submit  to  excision  of  the  coccyx.  Her  general  health  was  fair,  but 
there  was  decided  gastro-intestinal  disturbance.  The  pain  of  which  she 
complains  has  been  present  for  about  eighteen  months.  She  suffers 
chiefly  when  sitting,  sometimes  finds  it  impossible  to  lie  upon  her  back, 
and  is  apt  to  have  a  sharp  twinge  when  she  starts  suddenly  from  her  chair. 
The  pain  is  no  worse  at  defecation,  is  not  increased  by  pressure  upon  or 
movement  of  the  coccyx,  and  is  entirely  unconnected  with  any  lesion  of 
the  rectum  or  anus.  The  greatest  sensitiveness  to  touch  seemed  to  be  lo- 
cated well  within  the  sphincter,  upon  the  posterior  Avail  of  the  bowel. 
There  was  enlargement  of  the  womb  and  misplacement. 

From  these  cases,  which  are  both  good  examples  of  mild  forms 
of  the  affection,  it  is  evident  that  the  disease  may  vary  greatly  in  its 
severity.  In  some  persons,  it  will  cause  the  same  suffering  as  the  most 
intense  neuralgia  elsewhere.  The  pain  is  apt  to  be  paroxysmal,  but  may 
be  continuous,  and  is  independent  of  the  act  of  defecation.  In  cases  of 
well-marked  periodicity,  a  malarial  element  should  be  looked  for,  and  the 
disease  may  be  a  manifestation  of  the  gouty  diathesis.  In  the  former 
case,  quinine,  and  in  the  latter,  colchicum  may  be  of  the  greatest  service. 
In  all  other  cases,  the  treatment  will  often  be  found  unsatisfactory,  and 
is  to  be  conducted  on  general  principles.  The  first  care  should  be  for 
the  general  health,  the  second  for  the  regularity  of  the  bowels,  and  after 


■«<'•■- 

WOUNDS   OF   THE    RECTUM.  *  281 

this,  local  applications  of  cold  water,  ointment  of  beljfdonna  (  3  i.-  3  i.)> 
and  blistering  over  the  sacrum  may  bo  tried.  Besides  this  local  treat- 
ment, the  case  must  be  managed  exactly  as  vrould  be  a  case  of  neuralgia 
ill  any  other  part. 

The  diagnosis  from  coccygodynia  and  from  spasm  must  both  be  made 
with  care. 

Wotinds  of  the  Rectum. — Wounds  of  the  rectum  may  be  either  con- 
tused and  lacerated  or  incised.  Tiie  latter  most  frequently  result  from 
surgical  operations,  and  may  be  intentionally  inflicted  as  in  the  operations 
for  fistula,  or  for  the  removal  of  tumors,  or  the  result  of  accident,  as  in 
the  operation  for  stone.  Contused  and  lacerated  wounds  are  generally 
the  result  of  jiccident,  and  perhaps  the  most  frequent  cause  of  such  an 
injury  is  the  perforation  of  the  bowel  witii  an  enema  tube,  a  bougie,  or 
a  urethral  sound.  The  gravity  of  this  accident  will  depend  upon  two 
factors — whether  the  perforation  of  the  bowel  is  abo"7e  the  peritoneum, 
and  whether  the  enema  has  been  deposited  in  the  perirectal  tissues.  The 
latter  complication  will  be  followed  by  abscess  and  peritonitis,  and  will 
result  either  in  death  or  in  stricture  and  fistuhu  If  the  wound  be  un- 
complicated by  the  injection,  the  mere  puncture  may  I^Bal  spontaneously. 
It  is  oblique  from  below  upwards,  and  this  greatly  favors  spontaneous 
healing  without  faecal  extravasation. 

Esmarch  has  met  with  four  cases  of  this  injury,  none  of  which  were 
fatal  though  attended  by  much  local  trouble.  Velpeau  describes  eigiit 
cases,  six  of  which  ended  fatally.  Passavant  observed  five  cases,  one 
fatal.  Chomel  has  had  two  fatal  results.  There  are  two  preparations  in 
St.  Bartiiolomew's  Hospital  showing  the  results  of  this  accident,  one  in  a 
man,  the  other  in  a  child  ten  years  of  age  (Esmarch). 

Besides  thcsp  most  common  injuries,  many  others  may  be  enumer- 
ated. The  person  may  fall  upon  a  sharp  body,  as  the  point  of  an  um- 
brella (Bushe'),  may  be  caught  upon  the  horn  of  an  animal  (Gundrum;* 
Ashton),  or  may  be  impaled  upon  a  spike  (Esmarch*). 

In  such  cases,  the  accident  may  bo  immediately  fatal  from  collapse, 
and  the  wound  in  the  rectum  may  be  complicated  by  a  wound  of  the 
peritoneum,  or  of  any  of  the  adjacent  organs.  The  body  which  has 
done  the  injury  may  also  be  so  firmly  implanted  as  to  require  great  force 
and  an  anaesthetic  for  its  removal. 

The  rectum  is  not  infrequently  lacerated  in  child-birth,  and  although 
such  wounds  are  generally  of  sligiit  extent,  Bushe*  relates  a  case  in  which 
the  child's  head  was  passed  through  the  anus.  It  has  also  happened  that, 
in  a  violent  effort  to  expel  a  mass  of  hard  faeces,  the  rectal  wall  has  given 

>  Op.  cit,  p.  80., 

*  Detroit  Lancet,  Oct.,  187a 
»0p.  ')it.  p.  48. 

*  Op.  cit.,  p.  80. 


282  DISEASES    OF    THE    KECTUM    AND    ANUS. 

way.  Mayo'  relates  one  such  case  in  a  woman  of  forty,  in  whom  the 
rupture  was  in  the  recto-vaginal  septum,  about  two  inches  within  the 
bowel.  Ashton"  reports  a  similar  case  and  Bushe^  another.  Such  a  rup- 
ture may  be  either  vertical  or  transerse,  will  be  marked  by  sharp  pain  at 
the  moment  of  the  accident,  and  will  be  followed  by  a  discharge  of  blood. 
It  is  doubtful  whether  it  ever  occurs  without  previous  disease  of  the  wall 
of  the  bowel. 

The  consideration  of  gun-shot  wounds  comes  more  properly  within 
the  scope  of  military  surgery.  They  are  always  complicated  with  in- 
juries of  other  parts,  and  are  generally  fatal  from  extravasation  of  urine 
or  f  Eeces. 

The  complications  wliich  may  attend  a  wound  of  the  rectum  have 
already  been  hinted  at.  They  are  haemorrhage,  either  primary  or 
secondary;  faecal  infiltration;  purulent  infiltration;  peritonitis;  emphy- 
saema;  hernia;  invagination;  and  later,  stricture  and  fistula.  When  faeces 
are  forced  out  of  the  rectum  into  the  adjacent  tissue,  diffuse  inflammation 
and  gangrene  will  probably  result,  and  the  condition  must  at  once  be 
met  by  free  incisions  and  free  drainage,  as  has  been  described  in  the 
chapter  on  abscess.  The  danger  of  faecal  infiltration  may  be  lessened  by 
a  diet  which  shall  prevent  fluid  passages,  and  by  the  free  use  of  opium. 
A  dilatation  or  a  free  division  of  the  sphincter  is  also  to  be  recommended, 
so  that  a  free  outlet  may  be  accorded  to  the  contents  of  the  bowel. 

Emphysaema,  as  a  result  of  a  perforation,  is  generally  confined  to  the 
perineum,  but  may  be  diffuse.*  It  is  very  apt  to  be  fatal  from  diffuse 
inflammation  and  septicaemia,  due  to  the  putrid  nature  of  the  gas,  and  is 
to  be  met  by  free  incisions. 

"Wounds  of  the  bladder  or  urethra  communicating  with  the  rectum 
are  to  be  met  by  providing  for  the  free  issue  of  the  urine.  This  may  be 
done  by  catheterism,  by  asj)iration,  or  by  free  division  of  the  sphincter. 

"Where  none  of  these  complications  exist,  a  fresh  wound  of  the  rectum 
may  close  by  first  intention,  and  an  effort  should  always  be  made  to 
secure  this  by  rest  in  bed,  by  emptying  the  bowel,  and  keeping  it  empty 
by  frequent  washings  with  water,  and  by  the  use  of  opium.  Healing  by 
granulation  will,  however,  be  the  rule.  In  some  cases,  such,  for  exam- 
ple, as  laceration  in  child-birth,  sutures  may  be  at  once  applied. 

Alimentation  hy  the  Rectum. — The  fact  that  certain  substances  may 
be  absorbed  into  the  general  circulation  through  the  mucous  membrane  of 
the  rectum  has  been  abundantly  proved  by  physiological  experiment  and 
clinical  experience.  The  close  anatomical  resemblance  between  the 
inverted  follicles  of  the  rectum  and  the  intestinal  villi  render  an  analogy 


'  Op.  cit.,  p.  13. 

2  Op.  cit.,  p.  152. 

3  Op.  cit.,  p.  69. 
•'Lancet,  Jan.,  1860,  p.  89. 


AUMEMTATION    BT   THE   BBCTUlf.  28S 

in  function  extremely  probable  without  experimental  proof;  but  such 
proof  is  easily  obtainable.  A  solution  of  salt,  in  the  proportion  of  one 
part  to  eighty  of  water,  injected  into  the  rectum  will  disappear  com- 
pletely in  the  course  of  an  hour — so  completely,  that  an  evacuation  at  the 
end  of  that  time  will  be  found  to  contain  no  more  than  the  usual 
quantity.'  The  fluid  extract  of  rhubarb  may  be  detected  in  the  urine  in 
about  an  hour  after  being  injected  into  tlio  rectum  by  the  characteristic 
red  color  caused  by  the  addition  of  caustic  potash.' 

Bouisson,*  after  injecting  beef- tea  into  the  rectum,  found  the  lacteals 
charged  with  fluid.  Savory,*  in  his  experiments  on  the  relative  rapidity 
of  this  absorption  by  the  stomach  and  rectum,  found  that  strychnia  in 
solution  acts  more  quickly  by  the  rectum,  but  that  in  powder  the  relation 
was  reversed.  Quinine  should  be  given  in  larger  doses  by  the  rectum 
than  by  the  mouth,  while  chloral  and  belladonna  are  readily  absorbed  by 
the  former.  Curare,  on  the  contrary,  acts  more  quickly  by  the  rectum 
(CI.  Bernard).  Cubeba  and  copaiba  both  act  equally  well  by  the 
rectum;  and  water  charged  with  sulphuretted  hydrogen  gas  is  rapidly 
eliminated  in  the  dog  by  respiration,  as  may  easily  be  proved  by  the 
nsual  test  with  a  salt  of  lead. 

Tlie  fact  of  absorption  being  admitted,  the  next  question  is  as  to  the 
power  of  digestion  before  absorption,  and  upon  this  point  there  hjis  been 
considerable  discussion  of  late,  and  mucii  difference  of  opinion. 

The  theory  that  the  follicles  of  Lieberkiihn  may  take  on  a  vicarious 
action,  and  secrete  a  digestive  fluid  under  the  stimulus  of  albuminous 
food  placed  in  contact  with  the  epithelium  has  its  upholders,  but  has 
never  been  absolutely  proved.* 

Ar.other  theory  is  that  food  introduced  into  the  rectum  excites  secre- 
tion by  the  gjistric  and  intestinal  follicles,  and  that,  in  the  absence  of 
food  in  the  stomach  the  digestive  fluids  tiius  secreted  pass  down  into  the 
rectum  and  there  act  upon  the  injected  materials.* 

Still  another  theory  is  that,  instead  of  digestive  fluids  descending  to 
act  upon  the  food,  the  latter  ascends  to  be  acted  upon  by  the  fluids  in 
the  small  intestine,  and  is  there  fitted  for  absorption.^     This  theory  hjis 

'  Liebig:  Animal  Chemistry. 

*Smitli:  Suppleinentan.'  Rectal  Alimentation,  and  Eispecijilly  hy  Defibrinated 
Blood,  as  Applicable  to  a  Large  Range  of  Cjises  in  which  Nutritive  Enemeta  have 
not  Heretofore  been  Employed.  Read  before  the  N.  Y.  Acad,  of  Med.,  February 
20th,  1879. 

•Diet.  Encyc,  Art.  Rectum. 

*Gaz.  Mwl.,  1864. 

*C!.  H.  Stowell:  Is  Food  Digested  in  the  Rectum?  The  Medical  Advance, 
Januarj-,  1879. 

•A.  Flint,  Trans.  N.  Y.  Acatl.  of  Med.,  Feb.  20th,  1879,  and  "  Cases  Illustrative 
of  Rectal  Alimentation,  with  Remarks,"  Amer.  Practitioner,  Jan.,  1878. 

'  H.  F.  Campbell:  Rectal  Alimentation  in  the  Nausea  and  Inanition  of  Preg- 
nancy— Intestinal  Inhaustion  an  Imjxjrtant  Factor  and  the  true  Solution  of  its 
Efficiency.    Trans.  Gynaecological  Soc.,  1879. 


284  DISEASES   OF   TETE    RECTUM    AND    ANUS. 

grown  out  of  certain  facts  which  have  recently  come  to  light  regarding 
the  reversed  peristaltic  power  of  the  bowel.  Injected  matters  such  as 
blood  and  milk  colored  with  madder  may  be  found  on  j90s;f-7nor/e?/i  ex- 
amination evenly  distributed  over  the  coats  of  the  intestine  for  a  consider- 
able distance  above  the  rectum,  and  this  is  in  itself  a  simple  argument  in 
proof  of  a  reversed  action  of  the  bowel.  But  there  are  many  stronger 
ones.  Dr.  Battey,  in  an  article  on  the  ''  Permeability  of  the  entire  alimen- 
tary canal  by  enema,  with  some  of  its  surgical  applications,'"  details 
some  experiments  of  his  own  by  which  he  succeeded,  in  the  cadaver,  in 
passing  an  injection  from  the  rectum  through  the  whole  length  of  the 
digestive  canal,  and  out  of  the  mouth.  He  also  gives  certain  cases  in 
which  what  he  has  accomplished  on  the  dead  subject  has  been  done  by 
nature  in  the  living  patient.  In  this  way  he  accounts  for  the  undoubted 
fact  that  patients  will  often  complain  of  tasting  in  the  mouth  a  substance 
like  castor-oil  which  has  been  administered  by  the  rectum;  and  for  the 
fact  that  the  ingredients  of  an  enema,  or  a  suppository,  have  occasionally 
been  actually  vomited.  Dr.  Harris,  of  Milledgeville,  G-a.,"  has  recently  re- 
ported a  case  in  which  clear  beef-tea  enemata  were  vomited  after  an 
operation  for  ovariotomy. 

Jaccoud  records  a  case  of  faecal  vomiting  which  occurred  in  his  wards 
at  the  Lariboisiere,  in  1867,  in  a  young  woman  who  was  admitted  with 
hysterical  convulsions.  For  eight  days  this  person,  at  least  once,  and 
sometimes  twice,  in  the  twenty-four  hours,  vomited  veritable  f^ces, 
dense,  solid,  cylindrical,  of  a  brown  color,  and  with  the  normal  faecal 
odor,  coming  evidently  from  the  large  intestine.  Jaccoud  witnessed  the 
act  himself,  and  so  also  did  Dieulafoy,  and  he  characterizes  it  as  actual 
defecation  by  the  mouth.  Apart  from  the  passing  disgust  which  followed 
the  act,  the  patient  ate  as  usual,  and  continued  in  her  ordinary  health, 
except  in  the  absence  of  normal  action  of  the  bowels.  All  possibility  of 
deception  seems  to  have  been  rigorously  excluded.  Within  a  fortnight 
the  woman  was  seized  with  grave  typhoid  fever  and  died.     Careful  exam- 


» Virg.  Med.  Monthly,  vol.  v.,  1878. 

Note. — Dr.  Battey  makes  a  claim  to  priority  in  having  established  the  "  entire 
permeability  of  the  canal  to  enema,"  which  though  no  doubt  jjerfectly  just  as  fai 
as  his  own  experiments  go,  is  refuted  in  the  Med.  and  Surg.  Hist,  of  the  War, 
Med.,  vol.  ii.,  p.  836,  foot-note,  by  the  following  references. 

A.  Guaynerius:  Tractatus  de  fluxibus.  Cap.  2,  Lyons  Ed.,  1534.  History  of  a 
man  who  vomited  suppository  placed  in  the  rectum. 

J.  Matthias  de  Gradibus,  Practicia  de  ^gritudinibus  stomaci.  Cap.  6,  de- 
vomitu,  fol.  213,  Venice  El.,  1502;  History  of  girl  who  constantly  vomited  her 
guppositoriee  even  after  they  had  been  tied  with  a  string  to  keep  them  in  the  rec- 
tum. 

Morgagni,  references  to  numerous  similar  cases. 

*  Quoted  by  Campbell,  loc.  cit. 


ALIMENTATION  BY  THE  KECTCM.  285 

ination  of  the  body  disclosed  no  mechanical  obstruction  whaterer  in  the 
intestinal  canal.     The  ileo-caecal  valve  was  normal.' 

By  one  of  these  three  explanations  it  is  attempted  to  overcome  the 
obvious  ])hysiological  objections  to  rectal  alimentation  which  arise  from 
the  fiicts  that  albumen  is  not  diffusible,  or  if  so  at  all,  only  very  slowly 
and  in  very  small  quantity;  and  that  to  be  absorbed  it  must  first  be 
changed  by  digestion  into  albuminose.  Another  and  very  practical  way 
of  overcommg  the  obstacle  has  been  suggested  by  Dr.  Chadwick*  which 
consists  in  placing  the  enema  directly  into  the  small  intestine  by  means 
of  an  aspirator — a  procedure  which  might  be  considered  as  not  unat- 
tended with  danger.  Michel'  has  found  the  obstacle  insurmountable  and 
has,  therefore,  come  to  a  conclusion  unfavorable  to  the  absorption  of  the 
nutritive  matter  of  the  substances  injected. 

The  theoretical  difiiculty  of  the  digestion  of  albuminoid  substances 
has  been  practically  overcome  in  a  very  simple  manner  which  is  nothing 
more  or  less  than  artificialUy  digesting  such  substances,  either  before  or 
after  their  administration,  by  mixing  with  them  a  certain  quantity  of 
pepsin  or  freshly  prepared  pancreas.  Catillon*  has  performed  the  fol- 
lowing instructive  experiments  in  this  connection.  He  fed  two  dogs  for 
two  months  with  injections  of  eggs.  The  first  had  eggs  only  and  lived 
with  difficulty  and  with  considerable  loss  of  weight;  the  second  had  gly- 
cerin and  pepsin  mixed  with  the  eggs  and  lived  in  an  apparently  normal 
manner,  the  weight  and  temperature  remaining  constant.  After  thirty- 
seven  days  the  pepsin  was  stopped,  when  the  animal  began  to  lose  weight 
and  the  temperature  fell  3^'  Fahr.  The  conclusion  is  plain  that  for  nu- 
trition the  digestive  ferments  must  be  associated  with  the  food,  or  in 
other  words  that  they  must  be  transformed  into  peptones.  In  another 
series  of  experiments  the  same  author  has  demonstrated  that  the  same 
result  is  obtained  by  peptones  prepared  artificially. 

There  would  seem  to  be  no  doubt,  in  the  light  of  the  abundant  clinical 
evidence  which  has  now  been  accumulated,  that  life  may  be  supported 
indefinitely,  without  loss  of  weight,  by  the  proper  administration  of 
properly  prepared  enemata.  Flint*  refers  to  one  case  in  which  life  was 
80  sustained  for  fifteen  months,  and  in  which  the  feeding  had  been 
mainly  of  this  kind  for  five  years. 

For  the  convenience  of  the  practitioner,  the  following  formuloa  for 
nutritive  enemata  have  been  collected.     The  first  is  the  one  used  by 


'  Van  Buren:  On  Phantom  Stricture,  etc.  Amer.  Journal  Med.  Sci.,  October, 
1879. 

*  Amer.  Journ.  of  Obetet,  viii.,  Nov.,  1875. 

»Gaz.  Hebdom.,  1879. 

'*  Meeting  of  French  Ass.  for  Advancement  of  Science  at  Rheims,  1880. 
Abstract  in  Brit.  Med.  Jour.,  Sept.  18th,  1880,  p.  485. 

»  New  York  Med.  Record,  1878,  p.  56. 


286  DISEASES    OF    THE    KECTUM    AND    ANUS. 

Mayet'  and  approved  by  Brown-Sequard.^  Take  of  fresh  pancreas  of  the 
ox  from  one  hundred  and  fifty  to  two  hundred  grammes,  and  of  lean 
meat  from  four  hundred  to  five  hundred  grammes.  Bruise  the  pancreas 
in  a  mortar  with  tepid  water  at  a  temperature  of  S?''  C.  and  strain 
through  a  cloth.  Chop  the  meat  and  mix  it  thoroughly  with  the 
fluid  which  has  thus  been  strained  after  separating  all  the  fat  and  tendi- 
nous portions.  Add  the  yolk  of  one  egg.  Let  stand  for  two  hours  and 
administer  at  the  same  temperature  after  having  cleansed  the  rectum 
with  an  injection  of  oil.  This  quantity  is  estimated  by  Brown-Sequard 
to  be  sufiicient  for  twenty-four  hours'  nourishment  and  should  be  admin- 
istered in  two  doses. 

Where  the  pancreas  cannot  be  readily  obtained,  the  folio  wing  formula 
may  be  found  useful.^  To  a  basin  of  good  beef-tea  add  one-half  a  pound 
of  lean,, raw  beefsteak  pulled  into  shreds.  At  about  the  temperature  of 
the  body  add  one  drachm  of  fresh  pepsin  and  half  a  drachm  of  dilute 
hydrochloric  acid.  Place  the  mixture  before  tlie  fire  and  let  it  remain 
for  four  hours,  stirring  frequently.  The  heat  must  not  be  too  great  or 
the  artificial  digestive  process  will  be  stopped  altogether.  It  is  better  to 
have  the  mixture  too  cold  than  too  hot.  Sometimes  a  little  more  pepsin 
may  be  needed  which  may  be  ascertained  by  stirring  with  a  spoon.  If 
alcohol  is  to  be  given,  it  should  be  added  at  the  last  moment.  Eggs  may 
also  be  added,  but  should  be  previously  well  beaten.  This  preparation  is 
said  to  be  well  borne  for  a  long  time. 

The  formula  of  the  late  Dr.  Peaslee  was  as  follows:  Crush  one  pound 
of  beef  muscle  fine,  and  add  to  it  one  pint  of  cold  water.  Allow  it  to 
macerate  three  quarters  of  an  hour  and  then  raise  gradually  to  the  boil- 
ing point.  Allow  it  to  boil  two  minutes  and  no  more.  The  favorite  in- 
jection of  Dr.  Flint  is  milk  3  ij.,  whiskey  f  ss.,  and  the  half  of  an  egg. 
This  he  administers  every  three  hours,  day  and  night.  But  these  simple 
enemata,  no  matter  what  their  merits  may  be  or  may  have  been  in  the 
past  (and  we  are  inclined  to  Avonder  whether  all  attempts  at  alimentation 
before  the  admixture  of  pancreas  was  thought  of,  have  been  as  useless  as 
Catillon's  experiments  would  indicate)  are  now  generally  replaced  by 
those  of  artificially  digested  meat. 

In  the  year  1878,  many  experiments  were  made  in  New  York  with 
defibrinated  blood  as  an  enema,  and  the  conclusions  reached  were  em- 
bodied by  Dr.  A.  H.  Smith  in  the  paper  already  referred  to  and  were  as 
follows : 

*'l.  That  defibrinated  blood  is  admirably  adapted  for  use  in  rectal 
alimentation. 


'  Gaz.  Hebdom.,  Nov.  31st,  1879. 
2  Gaz.  Hebdom.,  Nov.  1-lth,  1879. 

*  Rennie:  Case  of  severe  cut  throat;  with  some  remarks  on  the  administra* 
tion  of  nutritive  enemata.     Lancet,  Oct.  23d,  1881. 


ALIMKKTATION  BY  THK  BEOTUM.  287 

2.  That  iu  doses  of  sixty  to  one  liundred  and  eighty  grammes  (two  to 
six  ounces)  it  is  usually  retained  without  any  inconvenience,  and  is  fre- 
quently so  completely  absorbed  that  very  little  trace  of  it  can  be  dis- 
covered in  tlie  dejections. 

3.  Tliat,  administered  in  this  way  once  or  twice  a  day,  it  produces, 
in  about  one-third  of  the  cases,  for  the  first  few  days,  more  or  less  consti- 
pation of  the  bowels. 

4.  That,  iu  a  small  proportion  of  cases,  the  constipation  persists,  and 
even  becomes  more  decided  the  longer  the  enemata  are  continued. 

5.  That  in  a  very  small  percentage  of  cases  irritability  of  the  bowels 
attends  its  protracted  use. 

6.  That  it  is  a  valuable  aid  to  the  stomach  whenever  the  latter  is 
inadequate  to  a  complete  nutrition  of  the  system. 

7.  Tiiat  its  use  is  indicated  in  all  cases  not  involving  the  large 
intestines,  and  requiring  a  tonic  influence  which  cannot  readily  be 
obtained  by  remedies  employed  in  the  usual  way. 

8.  T4iat  iu  favorable  cases  it  is  capable  of  giving  an  impulse  to  nutri- 
tion, which  is  rarely,  if  ever,  obtained  from  the  employment  of  other 
remedies. 

9.  That  its  use  is  wholly  unattended  by  danger." 

However  useful  and  nutritious  these  enemata  may  be,  there  is  one 
practical  objection  to  them  which  I  have  occasionally  met  with  and  have 
been  unable  to  overcome.  The  sight  of  the  blood,  its  administration, 
and  its  subsequent  voiding  are  not  calculated  to  impress  the  mind  of  a 
nervous  and  delicate  lady  pleasantly— on  the  contrary,  they  sometimes 
excite  the  most  profound  disgust. 

No  one  form  of  enema  should  be  continued  for  too  long  a  time,  and, 
as  a  rule,  patients  will  be  found  to  thrive  the  best  upon  an  alternating 
diet  of  milk  and  egg,  with  preparations  of  beef  and  pancreas;  alcohol 
being  given  as  it  is  indicated.  The  rectum  proper  will  seldom  accom- 
modate more  than  six  ounces  of  fluid,  and  this  is  the  usual  quantity  for 
an  enema;  but  the  sigmoid  flexure  will  hold  much  more  than  this;  and 
for  myself,  I  much  prefer  what  may  be  called  the  colonic  to  the  rectal 
method,  because  tlie  injections  are  better  retained,  cause  less  irritation, 
may  be  given  in  larger  quantity,  and  hence  need  not  be  so  often  re- 
peated. The  best  apparatus  for  this  purpose  is  a  small-sized,  soft-rubber, 
flexible  rectal  bougie,  the  end  of  which  will  accommodate  the  smallest 
end-piece  of  the  ordinary  Davidson's  syringe.  Tiiis  should  be  well  oiled, 
and  the  fluid  to  bo  injected  should  be  forced  through  it  once  or  twice  till 
it  is  well  warmed,  and  the  air  is  entirely  forced  out.  The  tube  is  intro- 
duced into  the  sigmoid  flexure  after  the  syringe  has  l)een  connected.  In 
this  way,  all  over-distention  of  the  rectum  and  consequent  desire  of  the 
patient  to  immediately  evacuate  what  has  been  administered  is  avoided. 
The  enema  should  be  administered  slowly,  and  by  the  physician  himself 
rather  than  the  nurse  or  relative  of  the  patient  ;  for  the  operation  is  one 


288  DISEASES    OF    THE    KECTUM    AND    ANUS. 

requiring  judgment  and  skill,  and  on  the  success  of  the  method  depends 
the  life  of  the  patient  in  most  cases.  It  is  always  well  to  empty  the 
bowel  by  a  simple  enema  before  administering  nutriment  at  least  once  a 
day.  With  proper  care  in  using  the  syringe,  the  rectum  and  sigmoid 
flexure  will  generally  be  found  to  submit  kindly  to  this  method  of  treat- 
ment, but  wlien  once  they  become  irritable,  unless  the  injections  can  be 
intermitted  for  a  day  or  so,  and  suppositories  of  opium  be  substituted, 
the  treatment  is  practically  at  an  end.  In  a  few  cases  I  have  succeeded 
in  re-establishing  a  tolerance  by  rest  and  careful  treatment,  but  it  is  much 
better  so  to  manage  the  case  from  the  first  that  no  irritation  be  excited. 
An  enema,  for  this  reason,  should  never  be  administered  at  a  lower 
temperature  than  that  of  the  body. 

Dr.  Spencer'  has  described  a  suppository  which  he  recommends  in  the 
place  of  enemata.  It  consists  of  the  extracted  product  of  artificially  di- 
gested meat,  from  which  the  insoluble  matter  has  been  removed,  mixed 
with  a  little  wax  and  starch.  Twenty  ounces  of  meat  thus  prepared  may 
be  made  into  five  suppositories,  one  of  which  should  be  given  every  four 
hours. 

'  Practitioner,  Feb.,  1882. 


INDEX. 


Abscess,  boundaries  of  ischio-rectal,  73 
causes  of  deep  rectal,  73 
classification  of,  71 
clinical  history  of  superficial, 

72 
course  of  pus  in  deep,  74 
diagnosis  of,  76 
distinction  between  treatment 

of,  and  of  fistula,  77 
due  to  diffuse  inflammation  of 

subcutaneous  tissue,  72 
due  to  disease  of  urinary  organs, 

74 
due  to  disease  of  neighboring 

parts,  74 
due  to  foreign  bodies,  73 
due  to  perforating  ulcer,  74 
due  to  rupture  of  the  rectum, 

74 
due  to  stricture  of  rectum,  74 
due  to  submucous  inflamma- 
tion, 74 
due  to  suppuration  of  Iwemor- 

rhoid,  72 
early  incision  in,  76 
following  surgical  operations, 

73 
horseshoe,  75 
how  to  avoid  the  formation  of 

fistula  in,  76 
involving  skin  of  anus  alone, 

71 
not  to  be  cut  into  the  rectum, 

77 
of  superior  pelvi-rectal  space, 

73 
of  ischio-rectal  fossa,  73 
originating       in       cutaneous 

glands,  71 
prognosis  of,  76 
19 


Abscess,  reasons  for  not  healing  sponta- 
neously, 75 
results  of  deep,  76 
rupture  of,   into  neighboring 

organs,  75 
symptoms  of  ischio-rectal,  74 
symptoms  of  pelvi-rectal,  74 
treatment  of  deep,  76 
treatment  of  superficial,  72 
Absorption  by  the  rectum,  283 
Adenoma,  malignant,  218 
Adenomatous  polypus,  188 
Albumen,  digestion  in  rectum,  285 
Alimentation  by  the  rectum,  282 
Allingham,  case  of  spasmodic  stricture, 
182 
ligature  holder,  84 
on  spontaneous  cure  of  fis- 
tula, 81 
on  treatment  of  deep  rectal 

abscess,  76 
operation  for  haemorrhoids, 

106 
results  of  colotomy,  216 
spring-scissors   for    fistula, 

87 
symptoms    of    ulceration, 
174 
Alveolar  sarcoma,  222 
Amussat,    oi)eration     for    imperforate 

anus,  39 
Ano-rectal  syphiloma,  149,  172 

syphiloma,   cause    of    stric- 
ture, 140 
syphiloma,      definition      of 

Fournier,  149 
syphiloma,  primary  seat  of, 

149 
syphiloma,  use  of  anti-syph- 
ilitic treatment  for,  149 


290 


INDEX. 


Anus,  abnormal,  34 

absence  of,  33 

congenital  malformation  of,  30 

description  of,  5 

double,  34 

erectile  tissue  of,  5 

imperforate,  31 

imperforate,  child  living  thirty 
days,  37 
Arteries  of  rectiuu,  13 

Baum,  case  of  colectomy,  244 
Benign  fungus,  148 

fungus,  composition  of,  148 
fungus,  haemorrhage  from,  148 
fungus,  treatment  of,  148 
Billroth,  case  of  colectomy,  245 

report  of  thirty-three  cases  of 
excision  of  cancer,  23  i 
Bivalve  speculum,  59 
Blood  for  rectal  alimentation,  286 
Bougies,  how  to  pass,  57,  192 

varieties  of,  56 
Boyer  on  fissure,  160 
Bridge,  case  of  colotomy,  216 
Broadbent,  on  puncture  for  reUef  of  ob- 
struction, 132 
Broca,  fatal  case  of  excision  of  polypus, 

142 
Bryant,  case  of  colectomy,  245 

villous  polypus,  137 
Bulteau  on  invagination,  125 

statistics  of  colotomy,  216 
Bursa  mucosa  coccygea,  10 
Byrd,  case  of  formation  in  anus  in  nat- 
ural position  after  colotomy,  45 

Calculus  projecting  into  rectum,  4 
Callisen's    operation     for    imperforate 

anus,  41 
Cancer,  218 

age  of  patients,  228 
causes  of  suffering  in,  247 
causes  of  mortality  after  exci- 
sion, 232 
causing  oedema  of  lower    ex- 
tremities, 230 
caustic  applications  in,  249 
chances  of  radical  cure  by  ex- 
cision, 234 
comparative  frequency  of,    in 

the  sexes,  228 
cure  of,  231 


Cancer,  diagnosis  of,  229 

dilatation  of,  249 

distinguishing  marks  from  be- 
nign polypus,  218 

division  of  sphincter  for,  348 

examination  for,  230 

excision  of,  231 

excision  of,  as  a  palliative 
measure,  235 

excision  of,  bibliography,  233 

excision  of,  contraindications, 
236 

excision  of,  compared  with 
colotomy  as  a  palliative  mea- 
sure, 235 

excision  of,  dangers  of  opera- 
tion, 237 

excision  of,  early  history  of, 
238 

excision  of,  how  to  perform,  288 

excision  of,  history  of  opera- 
tion, 231 

excision  of,  when  justifiable, 
237 

extension  into  neighboring 
organs,  229 

general  character  of,  218 

generalization  of,  220 

generally  painful,  229 

haemorrhage  from,  229 

indications  for  colotomy,  248, 
250 

insidiousness  of,  228 

involvement  of  lymphatics  in, 
230 

location  of,  228 

microscopic  anatomy  of,  219 

mode  of  development,  220 

of  sigmoid  flexure,  excision  of, 
243 

of  sigmoid  flexure,  diagnosis  of, 
231 

operation  of  crushing,  250 

opium  for,  248 

osteoid,  225 

palliative  treatment  of,  247 

partial  removal  of,  248 

peculiar  feel  of,  230 

prevention  of  obstruction  by, 
248 

proctotomy  for,  249 

regulation  of  passages  in,  247 

results  of  excision,  232 


INDEX. 


291 


Cancer,  secondary  ulceration  in,  229 
secondary  deposits  of,  231 
significance  of  pain,  229 
symptoms  of,  229 
treatment  of,  231 
Carcinoma,  melanotic.  224 
Cartilaginoustumor8(see  enchondroma) 
Cauliflower  excrescences,  143 
Cellulitis,  gangrenous,  around  anus,  75 
Chancre,  169 

frequency  of,  169 
Chancroid,  167 

as  cause  of  stricture,  168 
great  extent  of,  167 
spontaneous  cure  of,  167 
Clamp  and  cautery  in  treatment  of  col- 
lapse,  118 
for  removing  haemorrhoids,  108 
Clark,  A.,  villous  polypus,  136 
Co;;cyx,    excision    of,  for  imperforate 

anus,  39 
Coccygotlynia,  281 
Colectomy,  242 

analysis  of  cased,  246 
conclusions  concerning  ope- 
ration, 247 
history  of  cases,  243 
Colloid  cancer,  222 
case  of,  228 
distinction    from    encephaloid, 

254 
malignancy  of,  223 
mode  of  progress,  224 
Colonoscope,  60 
Colotomy,  accidents  attending,  42 

after-treatment  of  cases,  217 
choice  between  lumlxir  and 

inguinal  oi)eration,  43 
description  of  operation,  41 
for  stricture,  214 
history  of,  40 
in  cases  of  imperforate  anus, 

40 
limits  to  the  operation,  2ir, 
re-establishment  of  natural 

passages  after,  253 
statistics  of  operation,  215 
Columnar  recti,  8 
Concretions,  intestinal,  252 
Condylomata,  146 

as  sign  of  syphilitic  ul- 

ceration,  172 
definition  of,  146 


Condylomata,  description  of,  146 
diagnosis  of,  147 
non -syphilitic  nature  of, 

146 
undefined  use  of    term, 

138 
treatment  of,  148 
Congenital  cysts,  156 

malformations,      rules    for 

treatment,  37 
stricture,  31 
Constipation,  272 

causes,  273 
infantile,  278 
treatment,  274 
Crippson  cancer,  218 
Curling,  villous  p>olypus,  137 
Cusack,  clamp  for  haemorrhoids,  108 
Cysts,  151 

congenital,  156 

containing  foetal  remains,  155 
containing  liair,  152 
dermoid,  151,  153    • 
Czamy,  case  of  colectomy  266 

Defecation,  physiology  of,  19 
Depraved  sexual  appetite    accounting 

for  foreign  bodies  in  rectum,  262 
Depressor  for  rectal  examinations,  59 
Dermoid  cysts,  151 
Diagnosis  in  rectal  disease,  48 

cases  illustrating  errors,  48 
necessity  of  physical  exami. 

nation,  49 
position  of  patient,  52 
questions  to  l>e  asked,  51 
Digital  examinations,  54 
Dilatation  of  stricture,  199 
Discharge  caused  by  polypus,  141 
Divulsion  for  stricture,  200 
Douglas'  pouch,  6 

Dumarquay  on  treatment  of  fissure,  177 
Dupuytren,  <)j)eration  for  closing  artifi- 
cial anus,  46 
Dupuytren's    operation,     modified    by 

Barker,  47 
Dysentery,  166 

treatment   bj-   injections  of 
nitrate  of  silver,  180 

Eczema  marginatum,  270 
Edward  II..  niunlt-r  of,  2."J9 


292 


INDEX. 


Ecrasement   lineaire  in  the  treatment 

of  fistula,  83 
Elastic  ligature  for  fistula,  84 
Emmet,  rare  case  of  spina  bifida,  155 
Encephaloid,  223 

diagnosis  of,  222 
enucleation  of,  250 
rough  test  for,  222 
Enchondroma,  151 
Enemata  for  constipation,  275 
nutritive,  286 

nutritive,  how  to  administer, 
287 
Enterotome,  47 
Epithelioma,  220 

comparative      frequency 

of,  227 
cylindrical,  226 
Ergot,  injections  in  prolapse,  115 
Erythema,  272 
Esthiomene,  164 
Examination  table,  50 
Excision  of  cancer  (see  cancer),  231 
Extirpation  of  anus,  control  of  passages 
after,  28 

Faecal  vomiting,  284 

Fatty  tumors,  study  by  Virchow,  151 

tumors  (see  lipomata),  150 
Fenestrated  speculum,  59 
Ferrand,  case  of  prolapse  treated  by  in- 
jections, 115 
Fibromata,  149 
Fibrous  polypus,  149 
Fissure,  160 

associated  with  polypi,  162, 178 
associated    with      spasm     of 

sphincter,  160 
division  of  sphincter,  177 
due  to  hard  faeces,  166 
due  to  congenital  narrowness, 

160 
due  to  leucorrhoea,  160 
due  to  herpes,  160 
due  to  inflammation  of  a  sinus 

of  Morgagni,  161 
general  location  of,  161 
in  children,  178 
nothing  peculiar  in  ulceration, 

160 
ointment  for,  176 
pain  accompanying,  174 
painless  and  painful,  160 


Fissure,  passage  of  bougies  for,  176 

shape  and  appearance  of,  162 
stretching  sphincter  for,  177 
subcutaneous       division       of 

sphincter,  177 
symptoms  of,  173 
theories  concerning  causation, 

160 
tolerant  and  intolerant,  160 
treatment,  176 
without  spasm,  160 
Fistula,  blind  external,  78 

blind  internal,  73 

cases  in  which  operation  is  con- 
tra-indicated, 81 

causes  of  blind  internal,  80 

caused  by  stricture,  187 

classification  of,  78 

complete,  78 

deep,  78 

diagnosis  of  deep  from  super- 
ficial, 76 

dressings  after  operation,  88 

due  to  ulceration,  80 

due  to  previous  abscess,  78 

haemorrhage  in  operation,  88. 

how  to  detect  internal  orifice, 
78 

how  to  treat  in  phthisical  pa- 
tient, 82 

knife  of  author,  86 

in  connection  with  abscess,  79 

in  connection  with  phthisis,  81 

multiple,  80 

scarifying  old  tracks,  87 

spring-scissors  for,  87 

spontaneous  cure,  81 

structure  of  track,  79 

subcutaneous,  78 

submucous,  79 

submuscular,  79 

superficial,  symptoms  of,  80 

symptoms  of  blind  internal,  81 

treatment,  81 

treatment  by  cauterization,  83 

treatment  by  ecrasement  line- 
aire, 83 

treatment  of  blind  internal,  89 

treatment  of  deep,  89 

treatment  of  horseshoe  variety, 
88 

treatment  of   multiple  tracks. 


INDEX. 


293 


Fistula,  treatment  by  elastic  ligature, 

84 
treatment  by  incision,  85 
treatment  by  simple  ligature,  88 
treatment  when  tliere  is  no  in- 
ternal orifice,  87 
value  of  history  in  diagnosis,  80 
with  deep  and  extensive  tracks, 

80 
with  double  track,  79 
Flattened  feces  in  diagnosis,  188 
Foetal  inclusions,  154 
Forceps  for  ligating  haemorrhoids,  107 
Foreign  bodies,  256 

bodies  causing  abscess,  78 
bodies  causing  ulceration,  159 
bodies  causing  perforation,  259 
bodies,  complications  of,   258, 

264 
bodies,  general  treatment  of, 

258 
bodies    introduced   per  anum, 

260 
bodies,  prognosis,  268 
bodies,    pelvic  abscess    caused 

by,  259 
bodies  remaining  long  time  in 

rectum,  263 
bodies,     removal     by    laparo- 

enterotomy,  265 
bodies  swallowed,  256 
bodies    swallowed,    prognosis, 

258 
bodies,  treatment  of,  264 
bodie'»,  ulceration  caused  by, 

258 
Fouriiier,  ano-rectal  syphiloma,  149 
Fungus  ha-inatodes,  222 

Galvano-cautery  for  fistula,  88 

Gangrenous  cellulitis,  75 

Gangrene  of  rectum  after  confinement, 

178 
Gariel,  pessary  of,  54 
Glandular  polypus,  139 
Gonorrhoea  as  a  cause  of  stricture,  167 
Gonorrhuuil  proctitis,  69 
Gorget,  86 

Gosselin  on  chancroidal  stricture,  169 
Gummata,  148 

authorities  upon,  148 

rarit}'  of,  148 
Gussenbauer,  cases  of  colectomy,  244 


Hfemorrhage  from  rectum,  how  to  con- 
trol. 63 

secondarj',  after  applica- 
tion of  caustics  to  pro- 
lapse, 117 
Hsamorrhoid,  arterial,  97 

associated  with  uterine 
disease,  101 

associated  with  pr^- 
nancy,  101 

capillary,  96 

curative  treatment,  101 

cases  and  results  of  car- 
bolic acid  injections, 
104 

cases  unsuitable  for  oper- 
tion,  101 

definition,  91 

description  of  external,  93 

division  into  external  and 
internal,  91 

division  of  external  into 
venous  and  cutaneotis, 
92 

due  to  phymosis,  101 

external,  acute  inflamma- 
tion of,  94 

external,  formed  by  dila- 
tation of  vein,  98 

external,  in  a  child,  101 

external,  treatment  of  cu- 
taneous, 96 

external,  treatment  when 
inflamed,  95 

first  passage  after  opera- 
tion upon,  107 

forceps  to  be  used  in 
ligating,  107 

formed  by  extravasation 
of  blootl,  92 

internal,  diagnosis  of,  98 

internal,  varieties  of,  96 

internal,  metho<l  of  cure 
by  carbolic  acid  injec- 
tions, 105 

Internal,  operation  by 
clamp  and  cautery,  106 

palliative  treatment  of 
internal,  98 

suppuration  of  external, 
72 

suppuration  of  internal. 


294 


INDEX. 


Haemorrhoid,  symptomatic,  101 

symptoms  of  internal,  98 
treatment  by  caustics,  102 
treatment  of  external,  by 

incision,  93 
treatment    by     ligature, 

106 
treatment  when  strangu- 
lated, 100 
treatment    by  injections 

of  carbolic  acid,  lOB 
ulceration  following  ope- 
ration, 108 
various    operations    for, 

109 
venous,  97 
Hairy  cyst,  153 
Helmuth's  ligature  holder,  84 
Herpes,  273 
Hilton,  white  line  between  external  and 

internal  sphincters,  5 
Horseshoe  abscess,  75 
Hodges,  on  pilo-nidal  sinus,  153 
Hydatids,  154 

Impaction  of  faeces,  252 

of  faeces,  causes  of,  252 
of  faeces,  cases,  253 
of  faeces,  dilatation  of  sphinc- 
ter for  removal,  256 
of  faeces,   diarrhcea  caused 

by,  253 
of  faeces,  errors  in  diagnosis, 

253 
of  faeces,  location  of,  253 
symptoms  of,  253 
treatment  of,  255 
Intestinal  obstruction,  treatment,  198 
obstruction,    mechanism    of, 

191 
obstruction,  coming  on  sud- 
denly, 190 
obstruction,  fatal  when  cali- 
bre of  bowel  is  considerable, 
190 
concretions,  252 
Invagination,  134 

acute,  129 

change    in    evacuations, 

128 
chronic,  138 
diagnosis  of,  129 
degrees  of,  125 


Invagination,  extravasation  caused  by, 
137 
frequency    with     which 
different  parts  are  af- 
fected. 125 
faecal  vomiting  in,  128 
immediate  effects  of,  126, 
laparatomy  for,  133 
of  large  intestine,  128 
pain  in,  128 
pathological  changes  in, 

136 
peritonitis  caused  by,  127 
relative  frequency  of ,  126 
sloughing    of     included 

portion,  126 
symptoms  of,  127 
taxis  for,  130 
treatment  by  injections* 

130 
treatment    by   puncture, 

132 
terminations  of,  126 
tumor  caused  by,  128 
ulceration    and    perfora- 
tion caused  by,  127 
Imperforate  anus,  31 

anus,  rules  for  treatment, 
39 
Incontinence  of  faeces,  77 

of  faeces,  cure,  77 
of  faeces,  treatment,  77 
Incision  of  fistula,  85 
Inflammation  of  rectum,  66 
Inferior  haemorrhoidal  arteries,  13 

haemoiThoidal  veins,  13 
Inspection  of  anus,  53 
Instrument  case,  53 
Iodine  as  cure  for  fistula,  83 
Irritable  ulcer  (see  fissure) 
Ischio-coccygeus  muscle,  11 

Kleberg,   operation  for  prolapse    with 

elastic  ligature,  122 
Kohlrausch,  plica  transversalis  recti,  23 
case  of  stricture  due  to  hy- 
pertrophy of  valves,  184 
Kronlein,  case  of  attempt  to  re-establish 
anus  after  colotomy,  46 

Lamp  for  rectal  examinations,  51 
Laparatomy  for  obstruction,  138 


INDEX. 


295 


Laparo-enterototny  for  foreign  bodies, 

2.35 
Laugier's  instrument  for  examining  for 

stricture,  57 
Levator  ani,  1 1 

ani,  spasm  of,  18 
Licorice  powder,  compound,  99 
Lieberkilhn,  follicles  of,  9 
Ligament,  anterior  sacro-coccygeal,  7 

pubo-prostatic,  12 
Lipomata,  15U 

cretaceous    formations    on, 

151 
as  caiise  of  invagination,  151 
attached  far  up,  151 
divided    into    pedunculated 
and  non-pedunculated,  150 
study  of  by  Virchow,  151 
Little,  examination  table,  50 
Littre,  operation  of,  40 
Lumbar  colotomy,  dangers  in  children, 
43 
nerve-centre  governing  sphinc- 
ters, 17 
Lupus  exedens,  164 

exedens,  treatment,  165 
Lymphatics  of  rectum,  19 


Mackenzie,  on  the  treatment  of  dysen- 
tery by  injections  of  nitrate  of  silver, 
180 
Malformations  of  rectum  and  anus,  80 
Manual  examination  of  rectum,  61 
Marshall,  case  of  colectomy,  245 
Martini,  case  of  colectomy,  246 
Mason,  on  chancroidal  stricture,  168 
Maihieu,  rectal  supporter,  115 
Melanoma,  224 

analysis  of  cases,  225 
cases  and  literature,  224 
diagnosis  of.  225 
duration  of,  225 
general  character  of,  225 
location  of,  225 
malignancy  of.  22i 
Meso-rectum.  5 
Middle  htemorrhoidal  arteries,  13 

ha?morrhoidal  veins,  13 
Molk  on  foetal  inclusions.  154 
MoUiere,  ablation  of  prolapse,  121 

experiments  in  producing  pro- 
lapse, 113 


Morgagni,  columns  of,  8 

sinuses  of,  8,  22,  24 

Mucous  membrane,  glandular  layer,  9 
membrane,  muscular  layer,  9 
membrane,  valves  of,  21 

Muscles  of  rectum,  10 

Muscularis  mucosa?.  8 

Nerves  of  rectum,  16 
Neuralgia  of  rectum,  280 
Nitric  acid  for  haemorrhoids,  102 
Non-malignant  growths,  135 

stricture,  excision    of, 
214 
Nutritive  suppositories,  288 
enemata,  286 

Operations,  hcemorrhage  after,  63 
preparations  for,  62 
retention  of  urine  after,  65 

Osteoma,  225 

Osteocarcinoma,  225 

Osteo-sarcoma,  225 

Owen,  attempt  to  re-establish  anus  after 
colotomy,  45 

Packing  the  rectum  for  haemorrhage,  64 

Paget,  syphilitic  ulceration,  171 

Pain,  anatomical  explanation  of,  17 

Papilloma,  granular,  134 

Papillomata,  143 

Paquelin's  thermo-cauterj',  63 

Pederasty,  5,  159 

Pelvis,  measurements  in  children,  88 

Pelvi-rectal  abscess,  78 

Perforation  of  bowel  by  foreign  body, 

259 
Peristalsis,  reverse,  284 
Peritoneum,  contained  in  prolapse,  118 
in  polypus,  142 
relations  to  rectum,  5 
Peritonitis  due  to  stricture,  187 

from  jierf oration,  129 
Pig's  tail  in  rectum.  2.")9 
Pilonidal  sinus.  153 
Plica  transversal  is  recti,  2'-\ 
Polyadenotnata,  139 
Polypus,  ia5 

adenomatous,  138 

composed    of    hypertrophied 
villi.  135 

diagnosis.  141 


296 


INDEX. 


Polypus,  diagnosis  from    haemorrhoid, 
142 
difficulty     of     distinguishing 

from  cancer,  141 
danger  of  haemorrhage  in  ex- 
tirpation, 142 
discharge  mistaken  for  dysen- 
tery or  cancer,  141 
double  pedicle,  138 
examination  for,  141 
fatal  extirpation,  142 
fibrous  or  hard,  139 
large  vessels  in  pedicle,  142 
of  adults,  135 
recurrence  of,  140 
reduction  by  taxis,  113 
sarcomatous,  139 
secondary  diseases  associated 

with,  141 
soft  and  hard,  135 
spontaneous  expulsion,  141 
symptoms,  140 
treatment,  142 
villous,  136 
Polypi  of  childhood,  135 

associated  with  fissure,  162 
Posterior  umbilicus,  153 
Proctitis,  66 

causes,  varieties,  and  symp- 
toms, 68 
treatment,  70 
Proctoplasty,  38 

Proctotomy,  for  imperforate  anus,  38 
author's  knife  for,  205 
after-treatment  of ,  213 
cases  of,  206,  209 
cases  suitable  for,  213 
favorable  results  of,  213 
in  cancer,  211 
indications  for,  213 
internal,  202 
external,  204 
literature  of,  213 
Prolapse,  a  cause  of  stricture,  160 

ablation  of  old  and  extensive , 

122 
causes  of,  112 

changes  which  occur  in,  119 
containing  peritoneum,  118 
of  second  degree,  118 
of  mucous  membrane  alone, 

112 
palliative  treatment,  114 


Prolapse,  production   of,    by    inflating 
submucous  tissue,  113 
reduction  when  inflamed,  121 
reduction  in  case  of  circular 

slough,  121 
removal  of  first  vai-iety,  115 
removal  with  elastic  ligature, 

123 
strangulation  of,  119 
third    and    fourth    varieties, 

124 
treatment  by  clamp  and  cau- 
tery, 118 
treatment    by    cauterization, 

116 
treatment  by  injections,  1 1 5 
treatment  of  first  variety,  113 
treatment  when  operation  is 

contra-indicated,  119 
varieties  of,  110 
Pruritus  ani,  269 

ani,  symptoms,  269 
ani,  causes,  269 
ani,  treatment,  270 
Puncture  of  intestine  for  relief  of  ob- 
struction, 132 

Quain,  bleeding  tumor,  136 

stricture  due  to  hypertrophy  of 
valves,  184 

Raised  mucous  patch,  147 

mucous  patch,  development  of, 

147 
mucous  patch,  diagnosis  from 
simple  wart,  148 
Rectal  absorption,  283 

alimentation,  282 
depressor,  59 
supporter,  115 
touch,  how  to  practise,  54 
Rectitis,  hyperplastic,  149 
fibro-sclerous,  149 
Recto-coccygeus  muscle.  10 
Recto- vesical  muscular  fibres,  7 
Rectum,  arteries  of,  13 

congenital  malformation,  30 

curves  of,  2 

definition  of.  1 

development,  30 

divisions,  3 

dressings  after  operation,  65 


INDEX. 


297 


Bectum,  ending  by  abnormal  anus  in 
perin(>al  or  anal  regions,  84 

ending  in  blind  pouch,  33 

endinR  in  hhidder,  urethra,  or 
vagina,  86 

ending  of  longitudinal  fibres,  7 

excision  of  (see  cancer) 

fixed  position  of,  1 

haemorrhage  from,  67 

imperforate,  38 

layers  of  wall,  5 

length,  1 

lymphatics  of,  19 

mucous  membrane,  8 

muscles  of,  10 

muscular  coats,  6 

normally  empty  state,  27 

nerves,  16 
%  operations  upon,  62 

rules  for  examination,  etc.,  48 

relations  of  different  divisions, 
3 

submucous  tissue,  7 

total  absence,  37 

upper  limit  of,  2 

variations  in  position,  3 

veins,  13 
Retention  of  urine  after  operation,  65 
Retractor  recti  muscle,  10 
Roche,  case  of  fatal  rupture  of  prolapse, 

120 
Rodent  ulcer,  165 

ulcer,  diagnosis,  166 
Rupture  of  l)owel  in  prolapse,  120 

of  rectum  causing  abscess,  74 

Sarcoma,  alveolar,  222 
Sarcomatous  polypus,  139 
Scirrhus,  221 

extent,  222 
rarity,  228 
Scrofula,  as  cause  of  ulceration,  164 
Secondary  hamiorrhaRe  after  nitric  acid 

to  hjenmrrhoids,  102 
Sigmoid  flexure,  variations  in  position, 

48 
Smith,  case  of  divulsion,  231 

clamp  for  h«?morrhoid8,  108 

removal  of  severe  prolapse,  122 

Sodomy,  apjiearance  of  rectum.  159 

cause  of  ulceration,  159 

cause  of  vegetations,  144 

medico-legal  proofs,  159 


Sodomy  (see  pederasty) 
Spasm  of  levator  ani  after  operations, 
13 
of  sphincter,  277 
of  sphincters  associated  with  fis- 
sure, 160 
of  sphincters  associated  with  im- 
paction. 279 
Specula,  varieties  of,  58 
Sphincter,  dilatation,  60 
external,  10 
functions,  28 
internal,  10 
nerve  control  of,  17 
third,  7,  19 
Spina  bifida,  155 

bifid.i,  diagnosis,  156 
Stimson  o:i  cancer,  219 
Storer,  method  of  rectal  exploration,  53 
Strangulation  of  prolapse.  119 
Stricture,  attempts  at  spontaneous  cure, 
186 
bougies  for  detection  of,  192 
cause  of  abscess,  74 
cause  of  fistula,  187 
cause  of  peritonitis,  187 
cause  of  ulceration.  172 
congenital,  31 
dangers  in  examination,  55, 

57 
due  to  pressure  from  without, 

181 
due  to  hypertrophy  of  valves, 

184 
due  to  gonorrhoea,  167 
due  to  chancroid,  168 
due  to  traumatism,  185 
diet  for,  197 
difficulty  in    diagnosis  when 

high  up,  58 
following  removal  of  hemor- 
rhoids. 108 
general  treatment.  197 
how  to  measure  extent,  57 
manual  examination  for  diag- 
nosis, 62.  193 
mechanism  of  production  of 

flattened  faeces.  189 
non-malignant,  181 
non-malignant,  alternate  di- 
arrhoea and    constipation, 
188 
non-malignant,  cause  of,  181 


298 


INDEX. 


Stricture,  non-malignant,  change  in 
wall  of  bowel  capable  of 
producing,  183 

noa-malignant,  changes  in 
bowel  above  and  below. 
186 

non-malignant,  constitution- 
al remedies  for,  193 

rion-maUgnant,  dangers  of 
examination,  191 

non-malignant,  diagnosis  of, 
191 

non-malignant,  difficulty  in 
diagnosis,  191 

non-malignant,  divided  into 
venereal,  non-venereal,  ci- 
catricial, and  fibrous,  188 

non-malignant,  pathological 
anatomy,  186 

non-malignan  t,  probable 
causes  of  when  extensive, 
188 

non-malignant,  symptoms, 
188 

non-malignant,  treatment  by 
dilatation,  198 

non-malignant,  usual  seat  of, 
187 

non-malignant,  value  of  flat- 
tened faeces  in  diagnosis, 
188 

non- venereal,  184 

spasmodic  at  anus,  181 

spasmodic  at  rectum,  182 

spasmodic,  explanation  of 
supposed  cases,  183 

sudden  death  in,  216 

sigmoid  flexure,  treatment  of, 
217 

syphilitic,  but  not  ulcerative, 
183 

syphilitic,  specific  treatment 
for,  194 

use  of  long  cylindrical  spec- 
ulum for  examination,  193 

treatment  by  division,  202 

treatment  by  divulsion,  200 

value  of  dilatation,  200 

venereal,  183 

venereal  but   not    syphilitic, 
183 
Superior  haemorrhoicial  artery,  13 
haemorrhoidal  veins,  18 


Suppositories,  nutritive,  288 
Sustentator  tunicae  mucosae,  8 
Syme,  treatment  of  fissure,  177 
Syphilis  and  vegetations,  143 

diagnostic  marks  of  ulceration, 

171 
character  of  secondary  ulcera- 
tion, 170 
tertiary  ulcerations,  170 
late     manifestations      causing 
stricture,  183 
Syphilitic  stricture,  183 

stricture,  specific  treat  men  t» 
194 
Sympathetic  nerves  of  rectum,  18 
haemorrhoids,  101 

Talma,  autopsy  on,  186 
Tensor  fasciae  pelvis,  10 
Thermo-cautery,  63 
Third  sphincter,  19 
Transversus  perineei,  13 
Tubercular  ulceration  (see  ulcer) 
Tumor,  peculiar  bleeding  (Quain),  13d 
Tumors,  non-malignant,  135 
Trousseau  on  fissure,  160 

Ulcer,  caused  by  apphcations  to  fissure,. 

159 
caused  by  foreign  bodies,  258 
chancroidal,  167 
dysenteric,  166 
follicular,  164 
of  haemorrhoid,  168 
scrofulous,  164 
simple,  158 
tubercular,  162 

tubercular,  authorities  on,  163 
tubercu'ar,  cause  of  fistula,  163 
tuberc  ular,  cause  of  haemorrhage^ 

163 
tubercular,  cause  of  stricture,  163 
tubercular,  characters  of,  163 
tubercular,  course  of,  168 
tubercular,  distinction  between 

true  tubercular  and  ulceration. 

in  a  tubercular  person,  162 
tubercular,  location  of,  162 
tubercular,  treatment  of,  164 
venereal,  167 
Ulceration,  causing  abscess,  74 

caused  by  sodomy,  159 
diagnosis  of,  175 


INDEX. 


299 


Ulceration,  diet  in,  179 

division  of    sphincter  for, 

180 
following      operation     for 

htemorrhoids,  108,  159 
from  application  of  nitric 

acid  to  prolapse,  159 
from  childbirth,  159 
from  foreign  bodies,  159 
from  hard  faeces,  158 
from    surgical    operations, 

159 
gravity  of,  175 
harm  done  by  exercise,  179 
local  remedies  for,  179 
non-malignant,  158 
non-tubercular,  164 
occurring  during  the  course 

of  syphilis,  172 
8up{K>sitorie8  and  enemata 

for,  179 
syphilitic,    diagnosis    from 

tubercular,  172 
syphilitic,  cases  of,  172 
symptoms,  174 
treatment,  176 
treatment  by  absolute  rest, 

178 
treatment  by  large    injec- 
tions of  nitrate  of  silver, 

179 
within    rectum,   treatment 

of,  178 

Valves  of  rectum,  21 

of  rectum,  hypertrophy  of,  29 
Vance,  rare  case  of  fiscure,  161 
VanBuren,  operation  fcr  prolapse,  117 
spasmodic  stricture,  183 
speculum,  58 


Veins  of  rectum,  13 

Vegetations,  143 

causation,  144 
due  to  sodomy,  144 
relation  to  syphilis,  144 
microscopic   anatomy  of, 
143 

Venereal  stricture,  183 

Venereal  ulceration.  167 

Vienna  paste  for  hajmorrhoids,  102 

Vidal,  cases  of  prolapse  treated  by  in- 
jections, 116 

Villous  polypi,  136 
tumor,  136 

Virchow,  on  fatty  tumors,  151 

Vomiting  of  faeces,  284 

Warts,  143 

causing  symptoms  of  Assure,  145 
diagnosis,  145 
due  to  pregnancy,  144 
due  to  gonorrhoea,  144 
due  to  leucorrhoea,  144 
mistaken  for  syphilitic  condylo- 
mata, 145 
non-contagiousness  of,  144 
non-inoculability  of,  144 
powerlessnesa  of  specific  treat- 
ment for,  144 
symptoms,  144 
treatment,  145 
within  rectum,  145 
Wounds  of  rectum,  281 

of  rectum,  complications,  282 
of  rectiim,  treatment,  282 

Zappula,  case  of  supposed  syphilitic 
stricture  cured  by  antisjrphi- 
litic  treatment,  194 


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Kelsey,  Charles  B 

Diseases  of  the  rectum  and  anuf 


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Kelsey,  Charles  B 

DlseGuses  of  the  rectum  and  anus 


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